Melissa Singleton, Ph.D.: Good morning, everyone, welcome to this workshop that started a two day virtual workshop. Melissa Singleton, Ph.D.: designed specifically for our our friends at the National Partnership for healthcare and hospice innovation and pH I thank you so much, my name is Melissa Singleton and i'm chief learning officer for home centered care Institute, and we are so excited to present some really good information for you over the next two days. Melissa Singleton, Ph.D.: And I know we may have a few other folks joining and i've got. Melissa Singleton, Ph.D.: My sidekick Sarah was gonna help watch the waiting room make sure we're admitting people as we go but let's just jump in and so. Melissa Singleton, Ph.D.: Again i'm Melissa singleton chief learning officer i've got a few housekeeping things so we we do have this activity that's designated for CME or CE credit. Melissa Singleton, Ph.D.: And, as such i'm sharing these disclosures that no one in the Faculty or the planning team has disclosed any relationship with an ineligible company. Melissa Singleton, Ph.D.: Here is the information about CME and CE credit, we do designate it for a maximum of 12.25 credits over the next two days. Melissa Singleton, Ph.D.: You may be wondering how do I get that we will be sending you an email at the end of tomorrow that explains exactly how you. Melissa Singleton, Ph.D.: can claim that CME credit, you will be required to complete the evaluation in the HCC I learning hub so just be aware of that, but of course we're here, if you have any questions going through that process. Melissa Singleton, Ph.D.: And then you should have received an email from Sarah explaining how to access your HCC I learning hub and the materials there so i'm sharing this with you on the slide now. Melissa Singleton, Ph.D.: Our faculty will be referring to some of those materials and they're all posted individually for you to download. Melissa Singleton, Ph.D.: In fact, this is a question we included on our work on our evaluation, because we want to know do our learners prefer those individual downloads or in a. Melissa Singleton, Ph.D.: In one large workbook PDF we've kind of done it both ways so. Melissa Singleton, Ph.D.: we'd like to get your input on that, but, but this is how you would go ahead and access this you go to the HCC I learning hub using the link there you click on login and create account look for. Melissa Singleton, Ph.D.: Well, certainly you're going to log in then with your username and password and then. Melissa Singleton, Ph.D.: navigate to the my resources tab on the left and look for 2022 innovations and efficiencies and home based care. Melissa Singleton, Ph.D.: The HCC I solution suite and when you go in there you'll click on course and you'll be able to then see all of the workshop materials. Melissa Singleton, Ph.D.: And many of you also have been given access to some selected online courses for from HCC I and I listed those here, because this was included for three individuals from each registered practice. Melissa Singleton, Ph.D.: And if you do not see that and you want that you can talk to the person who coordinated your your your practices registration for this package, and we can. Melissa Singleton, Ph.D.: direct you as to how to add that for yourself, but these are the courses and, as always, if you need help with any of these things your go to is education at HCC institute.org if you have any technical issues during this call. Melissa Singleton, Ph.D.: Sarah breach you is monitoring that email, but you can also reach her in zoom chat I want to just do a shout out to Sarah do you want to just turn off your MIC and say hi everybody sees you and. Sarah Breesue, Ph.D.: hi everyone, you should have all received an email from me or multiple emails really it's really good to see everyone we're really excited to have you for this conference and, if you need any technical assistance i'm your girl. Melissa Singleton, Ph.D.: But it's always very reassuring to me, so thank you. Sarah all right now, I want to introduce our faculty. Sarah Breesue, Ph.D.: And we just have such a great group, these are some of my very favorite people i'm Dr Paul Chang is our senior medical and practice advisor at home centered care Institute. Sarah Breesue, Ph.D.: But in his day job he's medical director of northwestern medicine home care physicians and it's always just amazing to me because he recently made his 36,000. house call. Sarah Breesue, Ph.D.: that's 36,000 house calls in more than a 2021 your career so Paul, do you want to say hi. Paul Chang, Ph.D.: Here we go got the mute button off good morning everybody really excited to be here looking forward to a great day. Paul Chang, Ph.D.: And if we we've said this before we're here to to to teach and so on, but we all always always learn from you all from each other so really looking for a two way to a street and dialogue today so thanks everyone for spending today tomorrow with us. Sarah Breesue, Ph.D.: yeah i'm really glad you said that about the two way street because this is a relatively small group, we are going to have you introduce yourselves very shortly here, but there are 18 of you from. Sarah Breesue, Ph.D.: From four different programs and so as much as possible, we want you to keep your video on keep you know you know if you have a question you want to ask you can certainly unmute this should be very open, you know as if we were in a meeting room in a. In a facility somewhere so alright so next i'd like to introduce brianna brianna plenty is implementation manager at medically home. Sarah Breesue, Ph.D.: she's been a certified coder since 2014 and certified medical auditor since 2018. Sarah Breesue, Ph.D.: I I probably have learned so much for I have learned so much from brianna in the five years or so that i've known her because she was on staff at hcci until recently. But we are so thrilled that she continues to teach for us so Brianna do you want to say hi. Brianna D'Onofrio, Ph.D.: Good morning everyone it's so nice to see everyone and be here together so we're really looking forward to getting to know you all and spending time together in the next couple days. Sarah Breesue, Ph.D.: Thanks Brianna and next is Dr Ritu Suri who is owner and of a practice here i'm going to read this sorry I realized I. Sarah Breesue, Ph.D.: So she's a board certified in family medicine geriatrics and hospice and palliative medicine and medical director of a hospice for 19 years and then started her started their palliative care program, and so she owns reach you sorry. Sarah Breesue, Ph.D.: and associates MD and associates, which is a private practice specializing in geriatrics serving residents of bourbon county New Jersey in their homes. In their assisted living sniff and office and she's chief chief of family medicine at Englewood hospital. Sarah Breesue, Ph.D.: In New Jersey and she's national director of the palliative of palliative care for a hospice and former medical director of several skilled nursing facilities and former President of New Jersey post acute long term care and. Sarah Breesue, Ph.D.: The New Jersey New Jersey long term care leaders coalition so Dr sorry, would you like to say hi. Dr. Suri Chowdhury Good morning, everyone excited to be here i've learned a lot myself from the HCCI Institute and from Dr Chang's presentations before and have consulted brianna for our practice personally as well, so really excited to be here. Dr. Suri Chowdhury So, like everyone said, we are presenting you with a lot of information today, but I know that all of you have goals to achieve during this conference so really. Dr. Suri Chowdhury You know, a communication back and forth would be wonderful for us to be able to really cater to your needs, so please stop me in the middle of my presentation feel free, I am always open to questions I actually do better if I have questions so really want to give you all. Dr. Suri Chowdhury The opportunity to ask as much as possible. Dr. Beth Fisher Yes, I am and to that end um you know again that we've invited you, you can raise your hand and ask a question you can unmute and say hey I have a question. Dr. Beth Fisher You can also just put your question in the chat and our faculty will be monitoring the chat all day and can answer your question there as well, so our last faculty member isn't joining us until tomorrow and that's Dr. Aaron Yao and all of you should have received the custom market analysis report that Dr. Yao's team prepared specifically for your practice and so tomorrow morning he's going to be on and he will talk about the components of that market analysis report, the engine behind it and how to use some of those data analytics to achieve your goals and so you'll hear more from him tomorrow and so a quick overview of our agenda today we do have a kind of a jam-packed day, we're going to finish up with our introductions and icebreaker by about 10 30 central time, then we will have a presentation by Dr. Suri on the intersection of home-based primary care and palliative care, we will get into some details on getting started, key considerations when launching or expanding a house call program, that's from Brianna, we will break 30 minutes for lunch, I know that's not a lot of time but with a virtual workshop we need to kind of keep things moving, we want to end today by five because between lunch and five we've got coding, documentation, billing, we've got how do you survive and thrive in those dual environments of fee-for-service and value-based care, we will take a 15-minute break at 2 45 central and then finish up today with strategies for success, diving into some of the details and then self-care and avoiding burnout and then of course tomorrow we've got another full day between 10 a.m. and 5 p.m. central. The workshop objectives are shared on this slide, I'm not going to read through them, you should have, I think they're also on your agenda that you can download, but I'll move through here, but that's what we're accomplishing, quick word on your learning plan before we go into the icebreaker, this is a document that you can download from the HCCI Learning Hub and it's really, really valuable because I encourage you to download this now and have it open and as you're listening to the presentations jot down some of the things, you know, things, you know, topics that you hear about that you want to further explore or things that actions that you recognize you want to do or take or changes you want to make, things you want to be sure to remember, people or resources that you are identifying in the talks that wow, I really, I need this, I need to be looking into it and then, you know, some questions like based on what you've learned, what specific actions or changes are you planning for your own practice and what other topics might we be able to provide for you in the future. So just those kind of notes to provide a framework for that and then what will happen is we'll ask you to share this document back with us and our team will then refer to those during the next step, which is when we do a program development strategy session with you that's very individual and it's a way for us to help you reach those goals. So I do encourage you to fill those out. And then so we're going to dive into the icebreaker now and this is always fun because I'm going to try and pronounce names and make sure that I'm getting to everybody, but kind of going in alphabetical order because that's how it appears on my Zoom, alpha by first name. So I see Abner. Abner, would you mind introducing yourself and sharing your program name and role, how, what your level of experience is with home-based care and what are two things that you're hoping to get out of this workshop? And you could go ahead and unmute. Okay. Abner, are you there? Oh. So good morning. My name is Maria Medina and Abner works with me. I am the manager of the billing and we work at Nathan Adelson Hospice in Las Vegas, Nevada. Abner is actually in a training right now, but he's trying to listen at the same time. And once he completes that, he will join us. So. Well, would you like to, yeah, would you, can you share one or two things you'd like, you're hoping to get out of the workshop? Well, I'm hoping to learn more about the changes, any changes that we can implement for our palliative care program. So I'm open to listen to see what's out there and what we can improve on our end. Great. Thank you so much, Maria. All right. Allison Blight. Allison is also with Nathan Adelson. Yeah. So I'm Allison. I'm the director of the Elaine Wynn Palliative Program, which is part of Nathan Adelson Hospice. And I'm relatively new to this position and I was working on the inpatient hospital side for the majority of my career. So home-based care is completely new to me and I'm looking forward to learning a lot about how we can grow our program and help our patients even more. Great. Thank you so much, Allison. And so, so I'm going through all the Nathan Adelson people, I guess. Angela Collins. Angela, are you there? There we go. Can you hear me, Melissa? Yes. Yes. Okay, great. Thank you so much. Nice to see you all. Thank you for having us, by the way. My name is Angela Collins. I'm the chief operating officer for Nathan Adelson Hospice. For those of you that haven't been through some trainings with HCCI, you'll be very impressed. They did a beautiful job. So thank you for putting this on for the NPHI members, Melissa, and everyone else. So my experience with home-based care has been my experience at Nathan Adelson Hospice. So we say Nathan Adelson Hospice, but it's a full encompassing. So like Allison said, inpatient palliative, home palliative, which we're growing extensively, and then most recently primary care. So when you get to Kate, she'll be able to talk a little bit more about that. And Kate has wonderful experience in this already, but I think just for all of us, it will help us just be a little tighter, help us with, you know, those details and hopefully some efficiencies as well. All right. Fantastic. Thank you. All right. Let's see. Christy Dollar. Hello. How are you? Good. How are you? Good. So my name is Christy Dollar. I am the director of clinical informatics at Big Bend Hospice in Tallahassee, Florida. I'm fairly new to hospice and home-based care. So I've been, I'm a nurse by trade, ER nurse, and have been doing informatics for about 10 years, but I've been with Big Bend for almost two now. We just recently started a palliative care program. And then we are looking at starting a primary care program. So home-based primary care. So my level of experience is very minimal. I'm looking forward to just learning about, you know, how to set up home-based primary care, especially when it comes to the EMR, documentation, workflows, all of that fun stuff. So thank you for having us and doing this workshop. Thank you. And yeah, I mean, it's, it's always so helpful to hear some specifics about what you're looking for and I can go, uh-huh. I know we're going to talk about that. Uh-huh. I know we're going to talk about that. So, um, that's great, Christy. Thanks. Um, next is Deborah Morris. Hey everybody. I'm the medical director for the Transition Supportive Care Program, which is the home-based palliative program with Big Bend Hospice. So I work closely with Christy. I'm also medical director of the Tallahassee Memorial Healthcare Inpatient Program. And I've only been down in Florida doing this for about two years, but prior, I had about nine years of experience up in Virginia with a healthcare system and starting some home-based palliative services there. And things I'm most interested in learning is we seem to be in a, still a very fee-for-service-based environment down here in our community. So how do we prove our worth, stay afloat, and begin to venture into value-based metrics and programs um, and make the case to our stakeholders? And then I love documentation, making sure we're efficient and compliant and it's easy for our on-site providers to do the work. That's fantastic. Thanks so much. All right. Um, next is, um, uh, okay, uh, Delia Fauerfein. Am I saying that right? Hey, good job. It's Delia Fauerfein. Okay. Sorry. No, it's good. So I'm, I'm director of integrated care at Rockbridge Area Hospice in Lexington, Virginia. And I am, um, you know, kind of excited about, uh, just getting a deeper understanding of, of, um, home-based care and the kind of growth and expansion of, of our, um, community-based palliative care. Fantastic. Thank you. Um, Fabiola? Yes. Hi, good morning, everybody. My name is Fabiola Jean-Charles. I am the director of transition supportive care. I work with Christie, Dr. Morris, and Sue, uh, and Carl, whom you'll hear from in a bit. Um, but, um, this, so our palliative care program is new as of the last few months. So I'm new in this role, but before this, I managed a pre and post hospice program called transitions. So, um, I'm learning, I'm looking forward to learning more about, um, how I can be a better support in this role, not only to my staff, but to the community we serve. And, um, like Dr. Morris, I'm learning, I'm looking forward to learning more about the documentation, making sure that we're capturing what needs to be, um, you know, documented. So, um, and anything else, you know, I can, I can learn from all of you. So thank you for having me. I'm happy to be here. Thank you. All right. Next up is Francesca. Okay, we're going to come back to Francesca. How about Jameen Ellenwood? Good morning. I work with Snowline in Northern California. I'm the medical director and I've worked in hospice and palliative care for 22 years, but we've had a robust palliative care program for about the last seven years. What I'm looking to hear more about is how, as I see this as a very important aspect of caring for our aging population, but how do you keep this program fiscally sound? How do you staff this program? And we're venturing now, we have some value-based contracts and how do we show them the worth of this program so that they're interested in contracting with us for their home-based population. So that's what I'm hoping to get out of it. Thank you. All right. Well, thank you very much. All right. Carl Broussard? Yeah, thank you, Melissa. So my name is Carl Broussard. I am the chief strategy officer at Seven Oaks Health, whose subsidiaries are Big Bend Hospice and Transition Supportive Care, the palliative wing. What I am, or my level of experience in home-based care, right at 25 years of home-based care. The things that I'm going to be looking to get out of this workshop, the biggest thing is just how to prevent from recreating the wheel as we move forward in home-based primary care within the Big Bend region. And also much like Dr. Morris, just looking at how we can possibly transition from a fee for service world into a value-based world. Yeah, thank you very much. That's helpful. And the concept of not recreating the wheel, I mean, I think that's a lot of what we, HCCI has had the opportunity for the last five years to really gather some of the best practices from across the country and reflect that in our teaching. So we don't want you to recreate the wheel. We want to show you this is what we know works. So thank you. Yeah, good. Thank you. All right. Next is Kate Tuttle. Good morning. I'm Kate Tuttle. I'm a nurse practitioner. I'm Kate Tuttle. I'm a nurse practitioner. I work with Nathan Adelson Hospice. My role right now is in palliative care as well as primary care. We're building a primary care branch. I've been doing home-based primary care and value-based for the last six and a half years, six years. And I'm just really looking forward to learning more about it and billing, coding, kind of like Carl said, not reinventing the wheel. So I'm looking forward to it, and I know there'll be a lot of really great information here. Thank you. All right. Let's see. Kimberly Baxa. Hi. Good morning, Melissa. Thank you so much for having us here. So my name is Kim Baxa. I'm the director of financial services here for Seven Oaks, which is, again, how Carl described it. We're a subsidiary of Big Bend Hospice and Transitions Care. So I'm not exactly new to home-based care. So I have about maybe 10 years' experience in the palliative world. This is the first time I'll be crossing over into primary care. So what I'm really interested in is seeing the differences between the home-based primary care versus a home-based palliative care as far as billing and coding. And exactly as Carl and Dr. Morris described, really looking to see what we need to do to move away from the fee-for-service model and go more into the value-based world. So I'm interested to see what we can get out of the workshop. So thank you for having us, and I'm really excited about learning more the next couple of days. Thank you. That's great. Yeah, I know Brianna is going to share just a wealth of knowledge about documenting for home visits. And that applies to both home-based primary care and home-based palliative care, and she can help distinguish some of the important documentation elements there. So you'll be hearing a lot of that. All right, Lori Scoville. Lori, are you here? Hi, I'm Lori Scoville. I'm Snowline Hospice and Palliative Care's Chief Clinical Officer. I've been involved in home-based hospice since 2004, so 18 years, and in our home-based palliative care program for the last seven years. Today, I really hope to learn how can Snowline implement or expand our home-based program to continue to serve our community the way that we have, but also remain relevant in the current market today. Yeah, and I hear a lot of saying, we want to be able to serve our community. We want to be able to do that. And sometimes that means tightening up some efficiencies and workflows, right? Because this is not easy to do, and so we will be talking a lot about that, and hopefully that will help. You'll come away with some pearls for that. Thank you. So let's see. Maria, are you there? Yes, hi. I spoke earlier for Abner. Oh, you did? I'm sorry. Thank you for reminding me. I've got to watch my notes. Let's see. Tasha? Hi, I'm Tasha Walsh. I'm the executive director at Rockbridge Area Hospice. We also run a Connections Plus program. We're in a very rural part of Virginia, and we're jumping in with both feet with an ACO reach contract starting in January for high-needs population. Our medical director is also going to be working with an ACO reach general population. So really looking at how do we incorporate more of the medical visiting aspect to the high-needs population. Right now, our palliative care, the medical aspect of it is more consultative. And we have a very strong social work presence on our team, and that's really a big focus of it because of the needs in our community. Because we're so rural, we know we're going to have geographic challenges and things like that. So very excited about these two days. And I'm expecting my mind to be blown with some new like, ah, that's how we're going to do it kinds of ideas. So thank you for offering this to us. Thank you very much. And then Tim Meadows. Good morning, everyone. My name is Tim Meadows. I'm the chief executive officer of Snowline Hospice and Palliative Care in Diamond Springs, California, which is kind of midway between Sacramento and Lake Tahoe. So we serve a rural and an urban population. I've worked in skilled home health and hospice for about 16 years, everything from a mom and pop to large national provider. And definitely, I'm here to learn really what home-based primary care is and important considerations for us to keep in mind when starting up a practice. All right. Well, we're going to do that. So let's see, is Francesca back? I think I may have gotten to everybody that's on this call. Are you able to hear me? There you go. Okay, success. Oh, my goodness. I am so sorry about that. Well, very nice to meet everyone. My name is Francesca Mitten. I work with Big Red Hospice. I am the director of organizational change management. Hopefully, some people know what that is. It is dealing with the people side of change. But under my responsibilities, I also do project management. Similar to Christy, I am an RN, but I'm newer to the post-acute environment. And under my role, like I said, I do project management. So I'm going to be listening with acute ears to find out everything that takes, all the different tasks, all the different pieces and parts to set up the program so I can create a schedule and a timeline and key milestones and help the team create the project and the program. So I'm very excited to be here. Thank you. Oh, wonderful. Thank you. So did I miss any other learners from the four practices? All right, I think we got everybody. But let me also, there's just a few other guests I want to introduce. So Sarah Sharp from NPHI, I've worked closely with her to make this workshop happen. We've been talking about it since last spring. So Sarah, I don't know, if you're on, do you want to just say hi? Thank you so much, Melissa. Hi, I'm Sarah Sharp from NPHI. I'm the manager of the Center for Education and Vendor Relations. And I am so excited you are all here. You are in for an excellent couple of days. I had the opportunity to attend a similar session back in 2019. And all of the program, it was NPHI specific. We were all so excited. We were starting cohorts and ready to get going. And we all know what happened in January of 2020. So things, you all had to really change focus and just deal with what was in front of you with COVID. So we're so appreciative for HCCI and revisiting this and bringing this back. There is so much for you to learn. I know after the last session, a number of organizations engaged HCCI and worked with Brianna on billing. So again, you're in for a fabulous couple of days. Thank you so much, Melissa and the HCCI team. Well, thanks, Sarah. Now we're thrilled to be able to partner with NPHI once again on this. And to that end, I have two other members of my team that I wanted to just say hi. So first, Dana Crosby. She's our Senior Director of Engagement and Practice Development. Dana, do you just want to turn on your video and say hi? Yeah, can you guys see me? I think it's on. Yeah, great to see a lot of familiar faces. Even greater to see some new faces. Like Melissa said, I know you will learn a lot today and tomorrow. I too was at that first workshop, Sarah. I think I'd been here maybe six months in my role at the time. And it was just fabulous, incredible. So I know you'll all benefit. And I look forward to also learning from you guys while I listen in and listen to feedback and other areas that we can help with. So thanks for having me. Yeah. And Dana is going to be important because our relationship with these four practices doesn't end tomorrow. We're going to be scheduling some strategy development sessions with you to really talk through some of your individual goals and see what other resources we can provide or recommendations we can make for you. And so Dana is going to be integral in that. As will the next person I'm introducing, Tashir Times. Tashir is our new manager of practice development. And so Tashir, do you want to say hi? Yes, thank you. I'm Tashir Times. I am new to HCCI. So I think I'm in the reverse position Dana was in in that first conference. So I'm just here to learn and to learn HCCI and learn how I can be of service to you all in the future. And thank you for having me. Thank you. All right. Well, without further ado, we're going to go ahead and dive into our first session. And it's my absolute pleasure to turn this over to Dr. Ritu Suri. I'll be advancing your slides, Dr. Suri. But we're going to talk about synergies and solutions, the intersection of home-based primary and palliative care. Thank you. So good morning, everyone. And once again, so we're going to go directly into the slides, unless I think everybody had the objectives. We're trying to basically find an intersection between palliative and primary care, home-based. Obviously, we all understand the need. And a lot of hospices went and ventured into palliative care, I think very timely. And if they have not, I think hospices are the right place to start palliative care programs. In fact, I have started one for the hospice that I was the medical director for. So, and I think they are the, they should be able to help with the serious illness program. I actually had applied for that and CMS scrapped it, but hoping for it to come back in the near future. So let's go directly into the slides, Melissa. Okay, can you see the slides? I can see the objective slide. I can't see the next slide. Okay, I'll move to the next one. Thank you. Yeah. So as hospice providers and as palliative care providers, all of you have seen this kind of patient scenario. So a 65-year-old male with just recent discharge from the hospital, respiratory failure, on oxygen, obstructive sleep apnea, systolic heart failure, AFib, CKD, liver failure. Cirrhosis basically with ascites and all the other complications of that on 16 medications, two uninvolved grown children. So we're talking about the lack of support system here that he, this person has. He's had 11 hospitalizations between 2017 and 2018 and patient himself is very tired of doing this because it's a revolving door. We've all seen these patients who really do not have the support at home and who better to take care of these patients than an interdisciplinary team? And if you all have seen our healthcare system, there is only one arena where there is an interdisciplinary team that takes care of a patient. So which is the hospice setting. And prior to that, you know, it's, we all know it's pretty fragmented. The teams are not communicating with each other. So let's dive into the story and see how we can help and how this has, this should change for our patients. Melissa, next slide. So why, why home-based? I think the, the biggest question is why everybody's focusing on home-based care? You know, when we talk about right care, the right place at the right time. And I think I'm preaching to the choir because it is a lot of you are in hospice and you are used to providing care in the patient's homes. But the reason for the growth in home-based primary care, the home-based palliative care is because most of our patients live at home. Even though we know that 5% of our patient population, that is the top high spenders are spending that money in the hospitals or sub-acute, but most of the patients who really need care are still in their homes. And because of lack of access, lack of knowledge about the resources, you know, that is the reason they end up in those scenarios, but they are in their homes. And if we can provide them with care in their homes, they would be better off. We would see less expenditure. So in line with that, you know, the cost of aging, the chronic illness, obviously, which is a big push from the payer side, telling us that we need to provide the right care at the right place. We now have the technology to do that. And then there is obviously an exponential growth in the home and community-based services that are available at the current time. And the payers recognizing the value of house calls and the payment reform that has taken place, I think that is what they're talking, Dr. Cornwell is talking about this perfect stone that is helping us to push home-based primary care and palliative care. So if you need more information, obviously, this is a great place to go. So if you look at the first topic, we were talking about, you know, the rising cost of providing care to our elderly. So we have 10,000 baby boomers turn 65 every day. We know that our population is growing. We know that our population over 85 is going to quadruple by 2050. And we all know that 5% of Medicare beneficiaries consume 50% of our budget. So this is the reason for the biggest push. So I'm just going through these slides because they explain the five reasons for the perfect storm. So Melissa, next slide. So this is an article that was published by the IHI in 2017. And, you know, we, prior to the push for the home care, they had talked about the challenges of patient safety. And that is the reason that a lot of our patients were going to a skilled setting or right from the hospital were not going home, you know, because we were concerned about obviously their patient safety. Not about just that they're going to fall. Not of just household hazards, but also because the caregivers were not prepared to take care of the complicated patients. There was significant fragmentation in care. Like, you know, when they were discharged from the hospital, there was no community. Even though we had home care, the expertise in the home care setting of the home care providers was not, you know, there was no accountability. We were not really asking them that you are responsible for this patient once they are under your care. Also, the communication between the doctor who took care of them at the home versus, at the hospital versus when they come into the care of the provider at home. There was obviously inadequate communication between the patient, caregiver, and providers. And obviously the misaligned payment incentives, which to some degree still exist, because, you know, the cost of care that you, that somebody is reimbursed at the hospital level versus when they are at home is significantly different. So, you know, the push was, okay, you know what, rather than me going and seeing this patient at home, which is going to be X amount of dollars and X amount of time, I'm just going to go to see this patient at the hospital because I already have patients in the hospital. I'm just going to run and take care of this at home in the hospital. So there has been a lot of study into all of this. And, you know, this article is great. I think if all of you want to look at it, that you might be able to see a lot of opportunity when you, when you're, as you're designing the programs. So I have actually learned a lot from this article and did a lot of designing of my private practice model and our palliative care models that I've designed for the other hospice as well. So next slide, Melissa. This is a slide from CAP-C that, you know, I do a lot of palliative care talks, but I really, really, really love this slide because it tells us that, you know, and this is, this is the costs of a patient being cared for by a palliative care service and the others that are not cared for by palliative care service. And it speaks volumes because, you know, why people say, you know, we are providing home-based primary care. What is a palliative care service going to do? And when a home-based palliative care services in, and they are like wondering what is a primary care service doing? So I think there is a little bit of a tug of war here because I actually just presented to another large group that provides home care services. And I was talking about our palliative care services. And so there was a lot of pushback and they were talking about, you know, our NPs do this and our NPs do that. And then what is a palliative care going to do? But this slide speaks volumes and you can see that people who are getting care, usual care, and that is the primary care team is taking care of them. And if the palliative care team is involved, what the benefits are. And I'll tell you the real benefits. So when a primary care team is under fee-for-service, which is when this model was done, it is under fee-for-service in 2017, the primary care team needs to be running on a wheel, right? So you need to generate so many number of visits to be able to take care of so many number of patients on a particular day and answer so many number of phone calls, review so many number of labs. So if you've all read recent articles, they are talking about that a primary care provider to do what anyone is asking them to do, they need more than 24 hours. So your day doesn't even finish and your next day starts. So when the palliative care team is coming in, their focus is really on symptom management, care coordination, care management, and really advanced care planning. It is really another layer on top of the primary care. And it is to a certain degree to take care of, to take over some of the burden that the palliative care team has. And I'm hoping that as more and more palliative care programs get into the value-based care and more and more primary care providers will get into value-based care, a lot of this balance will shift, but as a primary care provider, you have a lot to take care of. So getting the help from palliative care team is really a supportive, not just for the patient, but for you. But the ultimate thing is that the outcomes are better. So next slide, Melissa. Yeah, this slide did not come out well, but I just like to go over this slide a lot. I love this slide. And as a hospice provider, as a palliative care provider, and as a primary care provider to understand where really this cost, the 5% spenders that we talk about are. So if you look at the dark blue, which is the 11%, it is basically those patients who are, 11% of our patients that amongst the 5% of the highest and costliest health spenders are basically patients that really belong on hospice. And they really have a short time span. They're mostly going to pass away within the six to 12 months. The 40%, sorry, the 49% are the short-term high spend. When we call like, I might have a 65 year old who has an MI, now needs a CABG, gets admitted, has complications after the CABG, then goes to subacute, has complications with subacute, gets readmitted to the hospital, but then comes out and then is fine. So, and then has, you know, as a stable prognosis. This is what our 49% are. The rest of the 40% are patients who we are talking about, they have a persistent high spend. And those are our patients with our chronic serious illnesses. And those are patients with dementia who have behavior or other complications. Then they are going in and out of the emergency rooms, going in and out of the hospitals. They are patients with CHF who are uncontrolled because of maybe several social determinants of health or non-compliance, or they don't understand their disease, or they don't have money to spend on their medications. And they are going back and forth to and from the hospital. They then are COPD patients who might not have the money to spend on their inhalers, or are, you know, MS patients, or are Parkinson's patients who are falling. So all of those patients who have these chronic serious illnesses who are basically living in the communities that they reside in and are in and out of the hospital. So it is this 40% of the population that we call the seriously ill population, or who have either fragmented care, who have lack of access to care, whose care is not coordinated, who really don't know how to manage their symptoms on their own, and have, you know, have high utilization of healthcare. And this is the population that we are talking about. And this is the population that resides in their homes. And this is the population that we hope to take care of. So Melissa, next slide. So this is another way of just telling you that the top 5%, how much they really actually spend. So if you look at the top 1% of the population is spending up to 130,000 per year. The top 5% spend approximately 61,000 a year. And look at the bottom half. The bottom half is spending a 374 total for the year. So this is just another way of telling you that, you know, our high cost patients really need well-coordinated care. And I give a lot of credit to hospice. I've been doing hospice for a long time. And the only place where we have an IDT really managing patients, and I think the hospice is the right place to take this over and take care of this seriously ill population. So kudos to all of you to start the programs. I am really, really excited for all of you. So next slide, Melissa. So this is the second piece of that. You know, now that we have the technology, just a way to tell you that we have a lot of technology that we can take care of our patients in their home setting. It just needs to be coordinated. So next slide. So this is the third point that we had talked about that, you know, the availability and of the community-based resources and the high caliber community-based resources. And now you all know that there is more, that even the home care organizations have to be more accountable for the kind of care they're providing. All their metrics, all their KPIs, and their star rating depend on the kind of quality care that they're providing and the services that they're providing post-acute. So next slide, Melissa. Again, it's just basically showing you that this is integrated home and community-based services. Patient survival in the community is much higher compared to patients who keep going in and out. So this was a independence at home, a Medicare program that had come out for home-based primary care providers. And this is the results of that. So the patients who had, you know, coordinated community-based resources available to them did much better. So next slide, Melissa. This is one example that we have provided to you for, you know, where one of the VA programs wanted to start a home-based primary care program. And so it is comparing the expenses that the VA had. And this is an excellent example of showing how home-based primary care program that they started really in the end made them save a lot of money. Because obviously upfront, there is a lot of, there is a huge cost to provide home-based primary care because you need, you know, you need a lot of support for the primary care provider going home. So you need a coordinator, you need a scheduler, you need, you know, obviously time spent in travel, obviously the cost of the provider themselves. You need to coordinate all these services, the labs, the x-rays, all of that. So you need support staff to be able to have your primary care provider going into the home. And so obviously the cost balloons up right in the beginning but if you see the next slides, you'll see that how the cost in the other areas reduced. So obviously outpatient, you want those services. Patient, you know, once you're going into their homes, you will see an increase in probable utilization of some of the services. Like they might be seeing their consultants more, they might have more pharmacy because they are more compliant now. There might be, and there might be a more x-ray cost and things like that. But you can see that there's significant reduction in the post-acute nursing home and the hospital costs. So the overall cost savings for the VA was approximately $9,000. So with a negative P value of 0.0001. So this is excellent, you know, slide to show that how much they saved by providing home-based primary care. So next slide. So again, so when you're talking about, you know, what is the value add from House Calls and, you know, to all those folks who are thinking of being part of the ACO who are wanting to be part of the value-based programs. And, you know, this is primarily how I presented myself when we partnered with value-based programs on our primary care side and on our palliative care side. And this is what they are basically looking for. This is what you can show. This is, there's no payer at this time who's not open to this. So if you look at, you know, in general, this is the top, the quality end-of-life care. I know there's a lot of information on these slides and I told Melissa that I'm not looking to go through each and every slide in detail, but I'm happy and open to questions. I can talk to you guys later as well. But we all know that the 25% of the Medicare dollars are spent in the last year of their life. And in general, patients passing away at home, 33.5% and on hospice are 42%. But if you look at that Northwestern Medicine Home Care Physician Program, you know, the number of patients that died at home were 76%. 77% of them died on hospice. Their median house call length of stay was 1.3 years and they reduced the hospital mortality and they also reduced ICU stays and hospitalization. So this is the kind of data that, you know, if you have. So I talked to hospices and they all have star rating and all of you know that. So when you are starting out your palliative care program, all of you worry about, you don't have data, but you do have data. You have data for you've taken care of these patients for an X number of days. At least most of your patients will have, you know, stayed on the program for anywhere from 14 to 180 days. That is where you need to check. Did your patients go back to the hospital? Did your patients utilize ER? There is a national standard for that and there is a standard for your own practice. There is a standard that you have for your practice. You need to be able to evaluate yourself against the other hospices and against the benchmark. And that is how you will present yourself to the payers when you're talking about your palliative care teams. Because what they're looking for is as a hospice provider, when you have access to the entire IDT, what was the level of care and quality and care that you provided and how it reduced their expenses. It reduced the expenses for the CMS and what they can expect from you as a palliative care provider going forward. So that is where the conversation begins. So I have actually presented to three payers and we have partnered with three payers in our communities and we have two very, very successful value-based programs in palliative care for the current hospice. And the third, we are just starting out. In our primary care, also, I have been a value-based provider. I entered that market very, very early because I was a solo practitioner. I really could not be seeing 30, 40 patients a day. I recognized that very early. I hated writing notes. Sorry, Brianna, you can close your ears. So I knew that I needed to change. I wanted to change. And so I went into the CPCI model. Then I went into the CPC. I was a track two provider. Now I'm in the primary care first provider in the model from CMS. And on that note, because of our outcomes from CPC, we actually partnered with Optum and Clover on our other two value-based programs. This year, we are signing up with Aetna and Horizon. So there are several ways to get into the value-based models. And I can just give you one example. And I know I'm just moving away from the slides, but I think the value for the providers is that right now, because we are in the value-based model, I went yesterday to a facility that I have. There is an IL and an AL. So I go to the IL in the morning and the AL in the evening. But because all of these patients are on the value-based model, I don't have to worry about really courting to level four visit because I'm getting a fixed amount for the visit. And I'm going to go into the details in the future slides. I really went in. I saw 18 patients. I couldn't even believe myself. And I was actually done with all my documentation because I really focused on, you know, one of them had shoulder pain. The other patient had a sacral stage two. The third patient had, you know, some GERD issues. The fourth patient had URI. So I really documented only maybe all level two visits, but I was not fearful that I have to, oh, my God, I have to make this into a level four. I have to find ways to stay with the patient and do this. I really was able to take care of the patients and their needs on that day because I did not have to worry about really generating all this income because we are in the value-based. We get, you know, fees for care management. So on the back end, I have my staff already, you know, taking care of whether they have their mammograms, whether they have their colonoscopies, whether they have their flu shot or their pneumovacs. You know, so I just want to tell you that this is such a relief for the providers. And I think what we talk about burnout, this is one of our ways to really switch, you know, to be able to take care of ourselves as well as our patients. So next slide, Melissa. Again, sorry for moving away from the talk. So, you know, this is the next point that Dr. Cornwell makes that, you know, there was a payment reform. Obviously, in 1997, we were getting paid, you know, for a follow-up visit $59, and in 2019, they increased it to $131. So you can see that, obviously, the payers also recognized that, you know, providing services at the right place at the right time really adds value to the patient and improves outcomes. So this is that slide. Next slide, Melissa. They've also added a lot of newer cohorts to, you know, to give incentives for you to provide care in their home settings, so obviously, prolonged services. You know, a lot of times, our home-based care, you might end up spending a lot more time with the patient because there is family dynamics. There might be social determinants of health that you're attending to. There might be other issues that you're taking care of, and Brianna is going to go into a lot of details. She's excellent at it. But the other cohort that I really like is the advanced care planning cohort that they came out with, the 99497, where you're really spending approximately 16 minutes face-to-face with either the patient or the decision-maker. If the patient is not able to or not willing to participate in their advanced care plan, that you will be able to spend that time with them to document their, you know, what their wishes were, are going to be, who their surrogate decision-maker is going to be. So I think, and then there is an additional code, 99498, which is for the additional 30 minutes, which I use quite often if I am doing a family meeting, you know, if I've had an initial advanced care planning meeting, and then the children will say, you know, I need to talk to, I need to involve other family members. And then we have a subsequent meeting. We have a family meeting discussing whether it is advanced care planning, the pulse, most, you know, we will frequently use that in those kinds of settings. Obviously, all of you are aware of the transitional care codes, less than seven days, you know, for high complexity patients, and for patients who are seen in less than 14 days in moderate complexity, you know, there's a separate code. There's care management codes, and then there is a complex care management codes for serious illness patients. And the complex care codes, in the chronic care management codes, that you need two diagnosis. And so it could be diabetes, hypertension, it could be diabetes and, you know, dementia, but in the complex care management codes, you could have one chronic serious illness that is making, that is affecting their prognosis, and that is affecting their utilization. You could actually do a complex care management on those patients as well. So next slide, Melissa. So this was the independence at home demo that the Medicare had was a model that came out of the CMMI. You know, so to enter the program, you had to be an experienced home care provider with over 200 patients under your belt. And, you know, they had to have more than two chronic conditions. Most of our home-based patients have that. Most of our home-based patients also have two ADL deficiencies, and they should have had high utilization. So the model themselves showed improved quality, improved patient satisfaction, decreased hospital and ED utilization, improved savings, and in the year one to five, they saw over 100 million savings, dollars of savings. So which is approximately $2,000 per beneficiary. So this was one of the models that I had demonstrated that increased utilization of the community resources improved the survival for these patients as well, and outcomes. Next slide. So this is a home-based palliative care program that was done by a ACO. So they had 651 patients enrolled in their program, but 82 enrolled in the palliative care program. So 569 were getting the usual primary care. And you could see that the cost of care the last three months was reduced by almost approximately $12,000 for patients who received palliative care. Their Medicare A, B costs reduced, hospital admissions reduced, and the hospice admissions increased, and their median length of stay on the hospice increased as well. So next slide. So these are some of the other programs that have come out from the CMMI, and which is one of them is the primary care first. I am one of the participants of that, my practices. And this is actually a, because CMS had two previous models prior to this, which was the CPC-I model, and then the CPC-II, so which were called the comprehensive primary care, the innovation model, then the CPC, which was the comprehensive primary care model. And this is an enhancement on those models. So this is essentially your population is looked at, all the providers, all the, sorry, all the beneficiaries in your practice are looked at, and they go over what is the average risk score for your practice. And they calculate that risk score based on their risk scoring system. They have your data from the last two years. And they give you a practice at risk score. And according to that risk score, they give you a monthly fee per patient. And all that money is provided to you at the beginning of the quarter. After that, if you need to make a visit for the patient, you need to, they're gonna give you a flat dollar fee. And you're evaluated every quarter. So every quarter you are evaluated for your quality scores, your utilization compared to the region and compared to your other practices in your area. And you're also evaluated from where you were last year to where you are this year. And then they go over your quality metrics, your spend, there is a performance improvement metric also. So when you do your QAPI, what is the performance improvement you've put in? And then there is a fourth component, which is the patient satisfaction. So what they're looking for is that they don't want the patient satisfaction to go down because they've changed the payment model. And they are looking, because as you're going to go into these models, it's gonna be very team-based care. And some patients are very used to having to deal with only the provider and they're not happy going into the team-based model. So you might see a little initial dissatisfaction. And I'm telling you this because we've gone through it. But as you educate the patients and the families and everyone else in the practice and to take over more responsibility, you will see that the patient satisfaction improves. Now, not to keep harboring that our practice has done it, our practice satisfaction scores have been really in the high 90s throughout the last five years in the CPC model. So we had to make a lot of changes in the initial years, but they were all well worth it. So there was another model that came out with the primary care first model, which is called the seriously ill population model. The CMS has scrapped this model for now. They are looking to really reintroduce this. And I think where this sits is in the hospices. Again, like I said, when I started the palliative care program, I did apply for this program for the palliative care for the hospice that I'm working with. And I think they have delayed it. This model was that they were gonna give you an initial visit fee, which was gonna be significantly higher than they were gonna give you a monthly fee and that there was a flat fee. And if you really were able to reduce their utilization and ER visits, you almost had a 50% upwards bonus. So this was the model that, you really needed the IDT to be involved because there was obviously patients that they were gonna assign to you who really had very poor and fragmented care, who had high HCC scores, had high utilization, and their care was not coordinated and really probably significant social determinants of health. But they really were having issues with how to attribute these. So they scrapped the model. But I'm sure that they're gonna have it in the future or something similar to that. Next slide, Melissa. So we have the other models that are out there are the direct contracting, which was out, but I think they have kind of slowed down on the direct contracting and changed the ACO reach model. There are other high needs population models, like the ones we saw the independence at home, there is primary care capitation models. So there are significant other models, but you need, that they do not need 5,000 lives, like the ACOs need at least 5,000 lives under their belt. So there are smaller models as well available. So like you saw the independence at home, you just had to have 200 patients and they have come out with some of these capitation models as well. So Melissa, next slide. So this is a slide which is showing you how many providers making home visits. It says 3,000 providers making over 100,000, over 1,000 visits annually. And there is another, next slide. Melissa, you have a big disclaimer. So we need 12,000 more providers to provide, to take care of the elderly that reside in their own homes and who need access to home care. So next slide. So this is just the workforce. It's just telling you that the most of the visits are provided by the nurse practitioners. So there's several internal medicine physician, family physicians. The physician assistant has recently been going up and we all know the reason that the physician assistant was because they had to be co-signed by a provider. So it was a real difficult way to provide home care that way, but I think you're gonna see an uptick in that as well. But a lot, most of the providers are nurse practitioners. Next slide. So this is the slide where you see the intersection between primary care and palliative care. And our primary care is again, dealing with all the preventative services, chronic disease management, some of the geriatric syndromes that, the falls, the incontinence and other issues that you guys are dealing with. Medication management, pre-op clearances and perioperative care and preventative care, so obviously, but, and there isn't a significant overlap again. So we do not have the number of palliative care providers that are needed to provide palliative care to every person who deserves it. We all know that. When I started out, it was, I think we had 1300 providers in the entire country. So we all know that we need to educate and train our primary care to be able to provide essential palliative care. And I think we all do. There is no questions about that. And even our oncologists are providing a lot of the symptom management because they are treating patients prior to chemotherapy with things that will minimize their side effects and complications. So every one of us, I mean, even cardiologists prescribe medications to help patients feel better and not have to feel like they're choking and they're drowning. So a lot of us are already using it. We probably don't recognize that we are doing a lot of palliative care, but what is it that the palliative care service is providing in addition to the home, the primary care team? So we are basically going in. So symptom management is always our biggest thing. We always wanna make sure that the symptoms are managed and sometimes the primary care teams are hesitant to think about morphine as a fourth line symptom management treatment. And I think the palliative care teams are more open to it. And then the other piece of that is symptoms do not just mean pain. So symptoms can also come from existential crisis. Symptoms can come from emotional, or even at least, the need, is there a need because there is an existential crisis or there is a psychosocial need that our social worker can assess. Then, there are a lot of ethical issues when you are taking care of as a primary care team and you're having, again, to go through 19 patients in a day. So some of the complex family meetings, some of the ethics issues, and then helping the families transition to hospice. So that is basically what I see the role of palliative medicine is. Complex symptom management, what we define as difficult families, which are not difficult families, it's just because their needs have not been assessed and answered. Their questions have not been answered. And sometimes they just don't hear the primary care team because they feel there has to be another answer to their question. So somebody coming from outside, that in itself helps, and then transition to hospice. So that is what I see the role of the additional palliative care team. Next slide, Melissa. Melissa, am I on time, or am I really running late? I haven't kept the time, so. Well, I started you a little bit late, but I think we're gonna make up the time somewhere else. So I think we're okay. Okay, great. So a lot of, these are some of the lessons that we've learned from a lot of the practices that have done palliative care and home-based primary care. This is the gist of those lessons. Like, you obviously need a program champion who's somebody who's really believes in that home-based primary care and home-based palliative care is what our patients need, and our population needs. So I think a needs assessment on your program tomorrow is going to really talk about what your geography is, what is the analysis of your practice, what is the need in your population, and what kind of resources that you would need. I think that will really help you all understand what kind of resources you need to put in your program. But somebody really needs to believe in that mission and vision. We all know that there is going to be a lot more homebound elderly, as we all know that our population is aging, and they are going to be homebound or are going to need homebound services. So I think there is no questions about that. Obviously, as you're marketing yourself, the way we marketed ourselves, and I'll tell you what I had at that moment was not really focused on home care when I started my practice. I did make a few home visits here and there, but essentially our goal was to eventually bring them back into the practice. But the day we decided that we are going to start our home care program, we also decided that it's going to be our patients that have graduated and are unable to come to our office, that we are going to see them at home. Then eventually what happened, once everybody in the community learned that we are a home care provider, there was a bombardment of patients, like all home care agencies in the area, all the private pay agencies in the area. And because I've worked in this community for over 21 years now, they found out that we are providing home care services, everybody. Now, our program grew from 20 to 102 in less than two months. So for me, I did not have that kind of manpower. And I had to actually regroup our team, really find out who was interested in doing this. And we were fortunate that one of our MPs was really interested in doing home visits. So we had to obviously reassign roles for all of us. And she preferred to do home visits versus going to the nursing homes. And that's why we were able to take on this in two months, but that might not happen for everyone. And I hope it does, but it might not. So just really assessing the need of your community and assessing where you are is extremely important when you're starting the program. Next slide, Melissa. So obviously, we all know Fee-for-Service is definitely there as a payment source for home-based visits. I know there was some question about somebody saying that, what is the payment model? Fee-for-Service, there is basically no difference between whether it is a palliative care or primary care. You really do need to be able to code appropriate diagnosis of the patient. You need to be able to code appropriate diagnosis of a palliative care. So you really have to be mindful. As a primary care provider, you can code for anything. You can code for a fall, you can code for a URI, you can code for a UTI. You could code for type two diabetes, dementia, Alzheimer's, dementia with behavior. You could code from A to Z, everything. As a palliative care provider, the provider has to be very, very mindful. And again, all the other sessions are gonna tell you that, but this is from our personal experience. So what started happening was that, obviously I had NPs working with me and I wasn't reviewing every chart, but we started to get denials from our Fee-for-Service payers. And when I looked at those charts, the denials were because our palliative care providers were coding as fall. So when they go into a building to do palliative care, or they went into an assisted living to do palliative care, what they were doing was the nurse would grab them, oh, the patient fell, can you see this patient? And because the patient was on palliative care, the APNs went and saw the patient. So they're doing a favor to the nursing staff. And yes, it is important as a marketing tool, but again, you really need to educate your providers to make sure that they are linking this fall to the reason that the patient is on palliative care. The fall is not a reason for a palliative care visit. Now, if you link this fall to saying, there is polypharmacy, this patient has dementia and has behavioral issues and that's why they're falling, or so there are several reasons for this patient to fall and you can link it to that, is it because of the antipsychotics or is it because... So as long as you are able to, your major diagnosis should still be dementia and not falls and you can put fall as a second or a third or whatever, but your diagnosis for palliative care should be very different from the primary care diagnosis. So obviously there is the opportunity for value-based contract in primary care. And then KPIs, obviously you're going to look at your KPIs from patient demographics, not only your demographics, but also your ACC scores. So educating your clinical staff on how to code, and it's extremely important on how to code for the serious illness programs. And there are 16 categories, Brianna is excellent at that again. And she can go over, and there are a lot of resources HCCI has. I use HCCI to help my practices and my clinicians learn HCC coding. So there is a lot of resources they have as well. So you really need to do a thorough workup of your patient demographic, obviously the profile of patients that you're serving, their HCC codes, their pre-enrollment hospitalization and readmission rates. And again, what is their, then you're going to have to track what their ER visits and hospitalizations are post-enrollment into your program. And there are now quality metrics that are openly listed on CMS websites. They obviously, for a primary care provider, they're obviously looking at your preventative care. They're looking at colonoscopy, they're looking at BP control, they're looking at diabetes, they're looking at flu vaccines, pneumonia vaccines, and several others, and obviously depression screening. But for high needs, palliative care programs, they're basically looking for, are you really discussing advanced care plans? And how long does it take you to really have a good advanced care plan? Are you doing, are you providing care that the patient is really understanding? So there is a survey that they send out and they are, one of the questions is, I'm going to mess it up, but one of the questions is that, were your questions or your concerns answered by the palliative care provider? So that is a very big quality metric for a palliative care provider. And then both primary care and palliative care obviously have patient satisfaction surveys, which hospice is very used to. You guys have been doing patient satisfaction surveys much before any of the other divisions of healthcare was. Then obviously they want to look at how many palliative care patients went on to hospice? What was their length of stay on hospice? Was it, what was their utilization of hospital in the last two weeks of their life? What was their ER utilization in the last two weeks of life? So, and then place of death. So all of those are metrics that you need to be able to present to your providers and the payers, I'm sorry. And so how we started initially with our hospice because we really didn't have any data on palliative care because we hadn't done any palliative care prior to that. We were six months into palliative care in New Jersey and I went and presented in another state. So we used our New Jersey data to reflect on the kind of care and the processes that we had put in place. And then eventually we, alongside that, we also presented our hospice data. And, you know, a lot of that data is available on Trella. And I think I'm sure as hospices, you're all aware of Trella. A lot of that, the big data is available and you can drill it down to your providers too. So if it is, you know, your medical director taking care of those patients, why is that patient going into the emergency room? Is it because our staff could not make it to their home or we were not called by the patient or family? And so, you know, you tweaking your responses and, you know, creating a copy around that, why is our patient going to the ER and maybe, you know, even creating a root cause analysis as a copy, you know, to why your patients were utilizing the hospitals and ERs. I think all of those things, if you can show to the payer, all of these things mean a lot to them. All it means is that you are willing to work towards better outcomes. So that is what, when I say that patients, people say that we don't have data to go and talk to these payers. It is not only data. It is also the processes that they are looking at. It is the processes that you've put in place to make sure or ensure that, you know, you are going to be responsible for every patient or resident or, you know, in your program. So that is what is, that is what they're looking at. Melissa, next slide. So, you know, this is a nurse practitioner revenue model that, you know, was generated by HCCI. And I can tell you that if you look at, this is going to be in your handout, but I want to just make one point. Because I'm in the value-based world, this seems like, oh my God, how's any practice supposed to survive on this? And it is very, very true. Because just because this nurse practitioner has generated 153,000 and their salaries are going up, again, plus the support staff that you need to be able to support this nurse practitioner to provide the care in their home is enormous. So I think I am going to preach again and again and again that every one of us should strive to be in a value-based model if you want to thrive at the end. So this is just a great way of looking at, you know, what your nurse practitioner is possibly able to generate. But, you know, ultimately to be able to thrive in the environment of primary care, home-based primary care or palliative care, I think we all need to be in a value-based model. So next slide. So, you know, again, so as you're establishing, so process development and implementation is extremely important as all of you understand. You know, how are your referrals coming in? Who are your referral sources? What is the kind of intake you have? So I will tell you a little bit. And, you know, what we have done in our practice is we obviously have an intake and there is one person who does our intake because it helps families to be able to talk to one person. And then we have our medical assistants enter all this data for the provider who's going into the field prior. So whatever, you know, records we can get, whether it is, and we are part of a, what am I going, the HIE from New Jersey. So we get all the data from there. We also have access to obviously the nearby hospitals, their data because I'm on staff in most of those hospitals. So we get all the information from everywhere. We try to enter as much as possible prior to the provider making the visit. And that is why I say that, you know, you really need to be in a value-based system to be able to provide that team-based care because if all that data is entered, the medications are reconciled, my medical assistants call the families, they prep them on the things that they should have, you know, make sure that your medications are out, make sure if you have a living will that is available for the provider, or, you know, all of those things are prepped. That way the visit goes very, very smoothly. And so, you know, I do stress this point because when you are designing a program to make sure that your provider burnout is not that high, I think this is an essential part of making sure that your providers are happy. We made a commitment in our practice to have a social worker, and we also have a psych nurse practitioner who works with us. But the, you know, the team really, really is helpful because sometimes the primary care provider gets so bogged down with, you know, they don't have meals, they don't have transportation, and they need to get somewhere. And then what happens is that the other stuff, which is very, very important for their medical provider to take care of, and especially talking about, you know, their serious illnesses and how to manage and what medications and how to improve compliance and all of those things. So if my provider is noticing on the first visit itself that there are so many issues, we get our social worker involved right away. So she makes the call, then they make a visit. The next visit is actually usually a combined visit. And then, you know, the social worker can take off from there. And then obviously making time in their schedule available to make the transitions care visit is extremely important and how to schedule all of this. So we are fortunate that we have two nurse practitioners making home visits for us. And so we are able to juggle that. And we try and see every patient within seven days who's going home. And the last visit we make is within 48 hours. We really go through their medications. And I will stress one more point here is that, you know, everybody just goes through their medication list that they have at home. Please, please, please make sure that you have the medication list from the hospital when you've reconciled their visits. So again, that is one thing if the medical assistants in the office or the RN in your office can take over, the provider who goes in. And obviously we need a triage and after hours support. You need 24 hours, seven days a week support. There was no questions about it because otherwise there is no way you can reduce ER or hospitalizations. So next slide. So, you know, there are several models. Obviously there are a lot of physicians who make home visits, but ours is more of a collaborative model in our practice. I do make home visits at least once a year for every patient, but most of the other visits are made by my nurse practitioners. If there is a need, you know, the nurse practitioner, they know that I can do a video call with them. We usually plan them in advance. Like, you know, it could be a wound that they want me to look at, or, you know, it could be a rash that they don't know what it is, or it is, you know, when we are having goals of care conversations, sometimes the families want, you know, me involved in the conversation. So we'll do a video visit at that time. So it is, so for the reason that I wasn't making all the visits, what we started doing is we have an interdisciplinary team meeting on one of the week mornings. And, you know, our social worker, geriatrics, APN, the NP involved with the patient and myself, we all, and the medical assistant, actually, we all meet and, you know, go over the cases. So if there's anything pending, any concerns that we have about the case, or, you know, any medication adjustments that I feel that need to be made, or any more resources that we might need for those patients. So I think that is what we do in those IDT meetings. Pretty much like the hospice IDT meetings. I learned the concept of IDT team meetings from the hospice. So thank you. And again, so you will probably need all these, you know, a program coordinator, obviously, a medical assistant, nursing, NP, PA, MD, and a social worker. So you have regulatory and compliance requirements. You know, so I saw this, but, you know, our home care program is strictly part of our practice. But for hospice and palliative, every state has a different requirement. So in New Jersey, they, you could not start a palliative care program without a physician being involved and being the owner of that. I don't know the rules of every state. Please review everything for every state. Like in Arizona, I know that because I have my cousin there doing this, they can, you know, a non-physician can open an entity and do that. But New Jersey, you cannot. Again, there is, the last point is credentialing. Now, credentialing is extremely important. Otherwise, you won't get paid. CMS is easy. You know, once you get the NPI number, the 855-I, R, 855-R, to reassign the benefits of the provider to your organization. But other Medicare Advantage plans all need to be credentialed separately. So please make sure that your providers are credentialed with all of them. Otherwise, you won't get paid. It sometimes takes 60 to 180 days to get a provider credentialed. So as soon as you think that you're hiring this provider, start the process. So next slide. EHR, something that we all have to deal with, you know, is extremely, extremely, extremely important. So I know hospices have been using EHR now for a while. And, you know, the hospice EHR is currently not designed to bill for primary care or for palliative care because I have done the, you know, the enhancements to our EHR that we were using in hospice for palliative care. And it was really cumbersome. It took us a long time to really include some of the things that we needed. Now that we are moving towards value-based care, and if it's going to be team documentation, it might, you know, be something that we could use hospice EHRs. But I still think that there is a lot of components that we want medically in the notes that are not able to be part of the hospice EHR. So I think getting a separate billing, I mean, a separate software for primary care and palliative care would be appropriate, at least at this time. And then the other point that I wanted to make was that, you know, if you are going to be the primary care provider and the palliative care provider and the hospice provider, I think you need to create an interface between the three. It will be really helpful, and it'll save a lot of time for your providers because then the meds can get carried over and everything doesn't have to be reentered into the system. And then there's obviously continuity of care and, you know, communication is much better. But, you know, the EHRs are, none of them is really optimized, but you really need to get your KPIs built in. Otherwise, at the end of the year or end of the quarter, you're going to be going in and manually doing all of that. That is a very big problem. And especially if you're looking to be able to present it to a pair, you really want this automated because when you go and present them something, they will come back and ask you for something else, which you might have to do manually anyways. But, you know, I think it is extremely important to get at least the basic KPIs built into your EMR so you can pull reports right out of that. Courting and billing, I'm going to leave it to Brianna. And Dr. Chang, geographic scheduling, of course, you do not want your providers to have more windshield time than, you know, seeing patients. So you really want to make sure that, you know, somebody is in a particular area of, you know, your geography, you try to schedule all their patients. And yes, of course, we have acute visits. We have, you know, TCM visits that need to be scheduled. They need to be done really in a timely fashion. You might have one or two of those, but, you know, most of your other visits should be in a pocket. Culture of continuous improvement, that is a big focus for every value-based program. So I think, you know, you could do a performance improvement in how you schedule, or you can do a performance improvement also on your courting and billing and also on your HCC scores or, you know, all of your processes, I think, is extremely important. But I think hospices usually have that mindset anyways, because you're required to have a copy and you've been doing it much before all of us were doing this. So next slide. Yes, obviously it speaks for, this slide speaks for itself. Market your program early, know your referral sources, you know, again, goes to the same point. You need to know your mission and vision and what is this program providing to your, you know, parent organization. And because there is going to be a time where you're really not gonna rack in a lot of revenue. So believe me, I've been on a lot of P&L calls and I've been on a lot of P&L calls and told that this is not doing well. So you will have a lot of expenditure on the front end because training your providers, you know, and then after the training, they need to train themselves because their speed might be much slower in the beginning. And so, and the communication and how the communication is gonna happen and how each of you are gonna depend on each other to take care of the different parts that a team needs to take care of. So there might be a lot of, you know, a lot of that learning that goes in. So there might be a lot of P&L calls that, you know, you're gonna see a negative, but eventually, as you add value, as you saw in the previous slides, where your expenses go down and then payers recognize that you president, you will see that this will pick up. And, you know, I can attest to that because this is my fourth year with the palliative care program. And I am proud to say that our P&Ls are in the positive now. So next slide, Melissa. So this patient that we started off with, you know, obviously the introduction of home-based palliative care, you know, his hospitalizations reduced. So again, how do we look at it? And, you know, when I go in and do a palliative care consult, I, my note has to look very different from every care notes, right? So I don't want the same, you know, 25 diagnosis listed that have, you know, continue care, continues as per primary care. That is not the goal of a palliative care consult. In my mind, and when I trained my clinicians to do this, so we now have roughly 25 APNs and, you know, several other physician providers who do consults as well. I really look for four areas in my note. Symptoms, if the symptoms are managed, the care is coordinated. And what I mean by care coordination is not in the real realm of the world that, you know, CMS uses it, but for my own reasons, I use this word is that I have spoken to the primary care provider. I've spoken to the oncologist. I have spoken to the patient's pulmonologist. I know exactly where this patient is in the trajectory of their illness and what their prognosis is. And if I don't know this as a palliative care provider, I do not think I can do the service or provide the service because the next two steps that I'm talking about, I will not be able to do it justice. So first is always symptom management when I go in. And if the patient is in distress, obviously my focus is to get that patient out of distress first. The second is always to coordinate with all these three providers and picking up the phone and calling the providers is the best way to do it because I cannot get it from their notes. Yes, I can get, you know, that the patient has COPD. Yes, I can get that they have cancer, but how many oncologists have you seen that write in their note that the prognosis is guarded? Never, almost never. Half the patients don't know that they are on palliative chemotherapy. So I need to pick up that phone and find out where they are on their trajectory of their illness. I need to know what their prognosis is as per their provider, as per their oncologist, as per their pulmonologist, as per their cardiologist, what do they think of that? And then once I have accumulated all this information, I then go on to my step, what I call care management, where I teach my patient that I'm consulting on how to manage their chronic serious illness at home in their own dwelling, whether it's assisted living, independent living, home, skilled nursing facility. How do they manage their symptoms? What do they have to do if they're short of breath? Do they take a rescue inhaler? If they have taken their rescue inhaler once, how often can they take it? When to call their provider? When might be a time for an antibiotic? When might be a time to start their steroids? When it is time to, you know, even things like using a simple fan to give them air if they're having a COPD exacerbation. When is the time to think about morphine as a symptom management? When is the time to really go to the hospital? All of these things, in my mind when I do care management is I have written it down for them to think about, you know, even when CF check patients, when they're taking their rate, how do they manage? Can they take their Lasix extra today? So all of these things that need to be done as care management. And then is the advanced care planning. And again, I will say the advanced care plan is only as good as the conversation. And if you have not had a discussion, if you don't know what their prognosis is, how can you actually have a good conversation with the patient about what their advanced care plan should look like? Do they have six months to live? Do they have next three years that they can think of? Or do they have weeks to live? It will look very, very different. And you know, there was a recent article about, it is really not doing justice to our patients if we don't tell them that their probability of how long they might have patient of our practice. And, you know, the mother was the caregiver for the son because the son is developmentally delayed. There is another son who's involved but lives out of state. Now the mother is not doing well. And so I had to have a conversation with the son who's out of state and who hasn't seen the mother in a while. And, you know, has been depending on the mother to take care of both of them, the mother and his brother. And so I was talking to him about hospice and things like that. And he was, do you really think my mom is dying? I said, I wanna ask you this. I said, would you be surprised if she's gonna be around in six months? So I think all of these conversations, hospice is excellent at having these conversations. I think we really need to make sure our providers that are going out into the field are comfortable with these conversations. And so part of the PI project that we did for our practice during COVID, you know, because some of these skilled facilities actually banned us from coming in and we were having a very hard time. So we started doing, we went to the UCSF website. They have e-prognosis and UCSF has also training videos. And we also used CAPTC, a lot of videos. We really went back to learning how to present diagnosis and prognosis to our patients and their families. So I think it might not be a bad idea if you're really thinking of doing a palliative care program or a primary care program, you know, to be able to make sure that your providers are comfortable with having these conversations. So for this patient, obviously they, you know, they got home-based palliative care, they got home health, they got the infusion service, you know, they needed for dehydration or for medication administration, obviously a lot of counseling, DME. So a lot of this was done. And so it resulted in reduced hospitalizations for this patient. So this is a success story for one of the patients in the program. But I know I've talked a lot. Sorry, guys, I love and I'm very passionate about this. So next slide, Melissa. So this is, you know, again, they're basically trying to say that there is a lot of forces that are telling you that home-based medical care is needed. It needs to be provided. The numbers are definitely increasing. We need more providers to do this. We need to really identify our seriously ill population. You know, and if you start out, there's nothing wrong in starting out small, you know? And if you really wanna start out and say, okay, we're gonna do this for only our COPD patients, or we are gonna do this only for our CHF patients, you can even start with that. Or you could do it with dementia. And there is so much with dementia that you can do. And as palliative care and hospice, you know, I'm actually starting a program for our practice on dementia because, you know, over the course of our five years that we've been in the CPC, we recognize the number of admissions for us was not because of CHF and not because of COPD. Our highest number of admissions were dementia and behavior. And, you know, which is obviously now we are responsible for overall cost of care, but we also need to make sure that, you know, our families that are going through a lot of angst, you know, at seven o'clock in the evening when the patient is sundowning, they need to have the support. So we need to, first of all, educate ourselves. So we're going through training ourselves. We have two training sessions scheduled for all of us. Then we are going through a training module, again, with the Alzheimer's Society. So there's a lot of things that we, again, it is really about training yourself to be able to train the patients and their providers in this home-based care. It's really about training yourself to train the provider, to train the care provider and the patient in their needs. So that's all I have to say. I am very happy to take questions. Okay, I'm muted, Melinda. Boy, rookie mistake, sorry. I want to thank Dr. Suri. That was really a great session. And the thing about our custom training, we kind of put these sessions together. We've not really done them in this way exactly before. And so we don't know exactly how long we're going to need, but I want to assure you that was all really great information and we'll be nimble and we may deviate from schedule, but that's okay. All right, so I encourage you to go ahead and put your questions in the chat for Dr. Suri. She's going to be back this afternoon to also do another session for us. And then we have more dedicated time for Q&A. At this time, I'm going to go ahead and move us to Brianna's presentation. I'm getting started. So Brianna, why don't you kick us off here? Thanks, Melissa. So we're going to start with this session a little bit more going through the business plan and kind of some of the things you might wanna consider, especially if you're a community palliative or dynamic palliative care organization that's thinking about adding home-based primary care and what does that really mean? And then later we'll kind of dive into some more of the details with staffing model and things like that. But if we go to the next slide, this is kind of what we're gonna talk about and how I'm gonna approach it. And if you haven't kind of tactically thought through all of these things, this is what we're gonna kind of encourage you to do through these two days with us. We'll go one more. I think sometimes we take for granted like actually strategically thinking about business planning and really trying to be tactical and have thoughtful answers too, specifically for your community because every area is different. You're gonna have different needs, especially if you're in a more rural geography than if you're in more urban. What is the need in your community? What does that patient population and that demographics look like? And if you're starting a new service line, what kind of skillsets are you bringing to the table to be able to solve for that? Especially if you're starting home-based primary care, you're probably great if you're a hospice and palliative doing symptom management and caring for advanced illnesses and having those difficult conversations. But is your team also prepared to manage their diabetes, their heart failure, to be the quarterback of all of their care, to not just be that consulting provider, but really to be responsible for not all of their medical and their social needs. And there's different approaches that you can take to that. When we think about longitudinal home-based primary care, that is you're providing care for your patients on a long-term basis. Again, you're caring for all of their chronic conditions as well as those psychosocial needs. And you really are the champion of their care. You could partner and maybe you're having more targeted support. Maybe you're helping with care management even for outpatient providers who have patients that they're still kind of co-managing with you. Maybe you're positioning yourself to start with home annual wellness visits. That could be a really good way to kind of even get your foot in the door for a pilot with a payer or certain organizations. And then we have seen practices that choose to really focus on that transitional care management where their average length of stay for their patients might only be one to three months. They're really coming in, they're getting discharge planners and hospitals that don't have great home-based solutions, excited about the fact that they can come in during a patient's most crucial time after discharge and provide that transitional care management. And then really kind of manage that patient until they're more stabilized to their other primary care option. And we've seen an explosion of home-based care services. So have you done a market scan and understand what are you missing? Is there really a need for wound care? And maybe that's something you wanna invest in hiring a wound care nurse practitioner or provider so that that can set you apart from the other competition in your area. So really understanding what the skill set and what the scope of services that already exist in your area are and how you're gonna make your practice different and how you're gonna stand out and kind of really solve that need in your community. Next slide. So as you're thinking about your business model and your distribution, Dr. Siri talked a lot about kind of how she approaches some of those conversations and what that value proposition is. But are you able to articulate, this is what these people and my patients need and this is how we do it. And then this is the impact of the care that we provide. Especially when you're going into the home, you have to kind of think about your distribution. How am I gonna get there? Am I gonna have company vehicles or what's my mileage reimbursement look like? Gas prices, certainly a factor now. When you're thinking about your revenue, are you gonna put a cap on certain percentages for certain payers? We all know Medicare and Medicare Advantage are pretty great options. Medicaid and some of those managed care contracts, it's really important to understand what that fee schedule looks like and what some of those things are before you get in there. And when you're developing your clinical model and identifying what patients you're gonna take care of, really being thoughtful about what your clinical model needs to have as far as standards and what kind of activities you need to do in order to deliver care to those patients while keeping an eye on costs. You're not gonna be able to afford all these expensive resources all at once. So how can you get creative about the infrastructure that you do have to deliver those services? And that's where I would kind of group those last three together with their relationships, resources, and partners. Identify and make a list and start conversations and build relationships with other complimentary community resources for your patients. If you don't have a social worker right away, what kind of home health agencies or other community agencies, sometimes maybe senior services have those resources that you can partner with. Who are you gonna be? Top referral sources that you know are gonna deliver quality care to your patients. And you've done that kind of initial vetting and conversations and kind of see who has that shared vision that can really kind of partner with you to meet the need. Next slide. So these are kind of some steps to make you think a little bit more about building the case. Geography is probably the most unique consideration. You cannot have a hundred mile service area and expect to be efficient in home-based primary care or community palliative care. So who are your stakeholders? Are there key partners that you need to understand? If you have a lot of home health agencies or maybe their stakeholders are your board or health systems or certain areas, what are those key kind of regions and zip codes? And have you really done that drive time analysis? Dr. Siri mentioned assisted living facilities or senior living communities. Those are great because you can travel to one place and see a cluster of patients. If you haven't mapped out in your area, what are all the different types of communities, not just assisted living, independent living, just senior kind of communities and populations, and especially the new buildings and the new constructions that you're starting to see developed. That's a really good idea to make sure you're mapping that out and identifying the centralized populations where you can come in and bring care. You also need to think about, you don't wanna just provide your service to everyone. We'll talk a little bit more about patient criteria, but who are you gonna serve and how are you gonna kind of articulate that so that your partners are referring the right patients to you and you're doing that little bit of screening so you're not just making a house call to everyone and really making sure that this expensive and comprehensive model of care is being provided to the right people and you're being smart about your resources. You've gotta have those strong, both clinical and executive champions. They should be great storytellers like Dr. Chang and Dr. Suri that are able to really kind of get people excited about this care, but then also have someone to kind of back up those operations. And when you think about marketing goals and strategies, it can be a little overwhelming too, especially as you're starting up, but you don't need to spend a bunch of money on fancy websites and things like that. We know that patients with multiple illnesses, older adults or even their caregivers probably aren't just going off the internet. So maybe you're doing an ice cream or an education event at these different kinds of communities. Maybe you're making sure you're linking arms with those home health agencies and different providers and you're setting yourself up for success from the beginning. We're gonna give you lots of metrics throughout these three days that you can consider, but pick three to five. How are you gonna know you're doing a good job and how can you, with your first five and 10 patients, start grabbing those stories like Dr. Suri went over to really show the impact of your care before they came to you and after? That is your value proposition. That is how you're gonna be able to go into a payer. I think with any payer conversation, you need a patient story and you need data to back it up. And you can start small and kind of go from there, but then really understanding where your providers or your facilities are, where do they live and what are those actual territory zones and maps and driving mile distance look like before you decide to start to offer services to people. Next slide. Couple of things that I didn't totally talk about. We'll give you some staffing model examples, but how do you use the people that you have, especially with an existing hospice and palliative care infrastructure in the most creative way? Where is there some opportunity for cross-training while you're growing your census? What kind of, again, that payer funnel, if you will, what kind of percentages from fee schedules of payers are you really looking for and being very tactical about that. Next slide. The other thing when you're thinking, and we'll talk more about this later too, but with marketing, is it easy to understand? We make house calls. We know through research at Home Base Primary Care, there's still a lot of people in this field that don't understand what that is. So house calls is a lot more friendly term than Home Base Primary Care. You can tell that this program, the other thing I like that they called out is, we focus on independence. We're adult primary care services at home. They're trying to use terms that are a little bit more easy to understand. And then saying, hey, you may have a mom or a family member with these kinds of conditions, like dementia, like Parkinson's, like diabetes and heart failure. Maybe it's just a mobility limitation, they're old age and it's just hard for them to get out of your home. Really making sure you understand how you're explaining the types of patients that you care for and making sure it's as easy as possible. Even if this isn't a website, if it's on a brochure, if you're talking to someone on the phone, all of these things are super important. We've given you some business planning resources in your handouts. Highly recommend, again, taking the time to do that SWOT analysis. As much as we're saying here's my value and here's what I'm gonna do, also being transparent about what's my risks and how am I gonna mitigate some of those weaknesses and some of those threats that might present myself when I'm starting this new program. I always like to share, especially for independent organizations that may be small to mid-size and not have the huge infrastructure behind you, there's a lot of resources for new businesses and new practices. The SBA, the Small Business Association, is one. Every area has a local branch or a local region. They'll give you a lot of technical assistance, especially if you're kind of stuck on the business licensing and how to set that up for free. So definitely encourage you to take a look. There's also the SCORE, Business Mentorship Program. This is gonna be more on the business while you figure out the clinical model. But just wanted to make the point that there are a lot of resources out there while you're getting started. So if we go to the next slide, I think this is what a lot of people struggle with because you don't wanna be too restrictive. Your patients don't need to be homebound. They need skilled home health services. You have to meet Medicare's homebound criteria. That's not what we're talking about in home-based primary care. We're talking about people who it's difficult to get out of their home. Maybe that's their frailty or mobility issues. Maybe it's because of their chronic conditions. Maybe they just have a lack of support and they're just those frequent flyers in the hospital and ED that could be a multitude of reasons. You could get more sophisticated with it, especially if you're part of an ACO or working with some of those aggregators out there and focus on patients with high HCC scores and kind of create an algorithm to identify potential patients. But really thinking about this and not feeling like you need to be restrictive. You don't wanna get the feeling that your patients have to be homebound in order for you to make a house call. They should be home-limited. They should need you for a reason, but you don't wanna be too restrictive when you're kind of talking about what patients you wanna care for. The other thing that you can kind of highlight is all of the things you're able to do in the home, right? So wound care, blood testing, and this is where you're gonna need your partners. What mobile phlebotomy, what mobile diagnostic service can you refer to for your patients? You're not always gonna be doing that. Some house call practices draw blood, others don't. Even outside of your visits, you're probably gonna need PTINRs or certain panels more frequently. So have you really established who those partners are? Immunizations, all of those kinds of things. Will you or will you not do procedures? Some house call practices will do trach and G-tube changes in the home, joint injections. Is that a skillset that your team has and are you prepared to offer that or will you not? So really being thoughtful about the breadth of services that you're gonna offer in the home. Talk about the different types of models. Again, a lot of times when I first started doing this, I used to hear like palliative plus, right? You're kind of in between offering full scope home-based primary care and those palliative care services. You know you have a bunch of those palliative care provider patients that really just don't have that relationship with the PCP. So what kind of service are you gonna provide and what kind of resources do you need to do that? How are you gonna expand? I think the opportunity for hospice and palliative care organizations is to really reach these patients farther upstream and earlier in their disease trajectory and be able to offer that continuity of care and care for that larger population of patients than you may be currently doing. Melissa, are you able to hear me okay? Yes. Okay, I saw a note from Dr. Siri and I just wanted to make sure before I kept going. Okay. So one of the things that I like about this, I stole this, this is CMS's definition of what is comprehensive primary care as they defined it through the primary care first model, which Dr. Siri talked about. But they put definitions behind these things. So as you're thinking about kind of what your clinical model needs to look like, access and continuity, they've defined that as you have to have 24 seven access. That doesn't mean you're gonna make a house call at all hours of the night, but do you have a triage or a call center that then can connect them with a provider after hours for support? That doesn't mean the call volumes after hours if you're doing really good education for your patients generally are not a lot, but they do need to have a way to review. And they're also looping in EHR access in this. If you're not using a certified EHR that meets those interoperability requirements, you're gonna be really limited in value-based care. When they talk about care management, they actually went on to define that as risk stratified care management. Are you able to look at your whole population and really identify they're all sick, we're caring for the sickest of the sick, but who really needs you? And when are you giving them more frequent interventions? Are you following up after the hospital or an ER visit or an acute episode from an exacerbation really timely? And are you able to prove and attest to that? Comprehensive initial coordination. They also call out specifically, how are you addressing behavioral health? How are you meeting your patient's psychosocial needs and what partnerships or what resources do you have to address behavioral health concerns? Patient and caregiver engagement. Maybe you're doing an annual survey. Maybe you have a patient and caregiver advisory group that's giving you real-time feedback. But when you start to get into these more complex models, they're wanting you to attest to that. They're gonna require you to have things in place. So if you're not already doing something like that, starting to think about how you're gonna get patient and caregiver feedback to incorporate into the care that you're providing. And then finally, that's okay, you can go on. With population health, they just wanna see that you're addressing preventative chronic care needs and that you're setting goals and continuously improving on them. So if you don't have that EHR infrastructure or you're not tracking those KPIs, it's gonna be hard to show that continuous improvement. I like this article from IHI. It was a 2020 article that was really starting to look at measuring complexity and kind of moving towards the standardization in complex care. And what I called out here on the slide are these are the key attributes that they said, this is what successful complex care models have in place. And some of this might seem straightforward, but we know that patients value timely feedback and coordination and medication management, all of those things. You really have to proactively outreach. You can't operate under this consultative model where you're just reacting to a problem or addressing the problem at hand. If you're gonna move into home-based primary care, you have to think about the full patient and how you're anticipating and proactively managing your disease when they're not in crisis and how you're gonna keep that communication and coordination with your patients. And then the other kind of, this is still focusing on the same article, but what social determinants of health impacts does your specific community have? How are you kind of meeting that need and considering those non-medical needs that your patients have that are gonna equally impact their cost, their outcomes, their care? Dr. Chang likes to talk about the patient and caregiver as a dyad. You're not there to just take care of the patient. You're taking care of the caregivers too. And you need to spend time understanding that care team relationship that the family members provide as well. So thinking a little bit more strategically about geographies, while you do need to be flexible, you cannot, it's a slippery slope if you say, okay, I'm gonna take this one patient that's technically 10 or 15 miles outside of my geography. How are you gonna routinely visit that patient if they're the only one in that area? So really understand and kind of set those standards and then just have a list of other referral services that if you get those calls to your staff that has huge hurts, doesn't have to feel bad, but set up a strategic geography that's also gonna be appetizing, if you will, to your partners and your stakeholders. You're able to kind of be that good partner and meet the need. Maybe you need to shift things around or look for hiring providers in different areas so you can do that. And then really being defined on that. Don't underestimate the value of senior living communities and facilities in your area. Home health agencies are the biggest referrals for home-based primary care. They need people to do those face-to-faces. They have really high-risk patients out of the hospital that don't have that follow-up. Really linking arms with quality home health agencies is important. And again, there's lots of, I know HHCI has provided you with some of that data and that market analysis too, but really using that to your advantage. Next slide. You could also think about it in terms of a primary and secondary market, right? The green is too far, too big, but we might wanna get there eventually. So zip codes are a great way to look at it, but you need to understand cities and boundaries and how many miles and how many hours it takes you. Typically within a 30 to 50 mile radius, I wouldn't recommend anything bigger than that to start with your home-based primary care program. Next slide. This is where it kind of ties into, and we're gonna talk more tomorrow about geographic scheduling tools and how you actually do this. But if you have a 50 mile radius, that's gonna tie into how many visits per day, more important in fee-for-service and values-based, but understanding the distance between locations and what cities or what zip codes you can even reasonably see on one day, and then developing a scheduling plan behind that. So again, these are just some examples from practices on how they're really tactically thinking about geography. Next slide. The other thing with values is, you have to hire the right people to speak to your values. This is what your organization believes. It's who you are as people and as an organization as a whole. And do you speak that? Do you, everyone that works there kind of live and breathe those actions and those values on a daily basis? This is really hard work and it's not for anyone. So especially in the interviewing process, be very transparent with what to expect, take them on right along so they can see house calls, really be able to articulate what's important to you and what kind of people from a culture perspective you're looking to join your team. Next slide. The other thing with branding is, everybody on your team should be able to have the same elevator speech, if you will, or have the same answer to when I say, what do you do? Oh, I make medical house calls, or we do medical visits for home limited, or older adults or people that aren't easily able to get out of the house. If you've done this exercise in a staff meeting, it would be interesting to see the different responses that you get when you ask people, what do we do? How would you tell someone when you bumped into them at our post-acute care conferences later this year, what we do in a succinct way that makes them wanna learn more or understand if they're a potential partner? When you're thinking about partnerships too, it's a two-way street, right? Like Dr. Thierry said, what do you need from them as a partner? You're probably gonna get a lot of opportunities. It might not always be the best fit, but what patients do you really want from them? Who are you the best equipped to take care of? And then understanding their needs as well, and then make it flexible. There should be, you should be talking about, these are the patients we want, this is how you're gonna refer to us, this is how we're gonna communicate. You should be at least having quarterly partnership meetings with your key partners to talk about how you're doing, to talk about shared patients. We know that relationships is a long game. Are you really understanding what you both need to do to be successful? Or are they asking for some really hard things? If you're starting to being asked to all these things that you know you don't currently have in place, you might not be ready for that partnership yet. So really understanding that, but then also making it really easy to partner and work together and being flexible and willing to adapt or try a pilot for the population they want you to take care of. Again, just highlighting some of those resources that Sarah mentioned that's available in the HHCI Learning Hub for you. All right, so we talked about the interdisciplinary team. You have the ability to get creative. We know that physicians, they tend to take more of a leadership or a medical directorship role. You're probably going to have a combination of physicians and nurse practitioners. How is that collaboration going to work? How are you going to use those physician assistants? We're certainly seeing them as well. When you're thinking about your clinical staff, there's a big difference between what a nurse can do and what a medical assistant can do, but there's also an expense difference. So, you know, medical assistants are great when you're starting out because they can do administrative and, you know, limited clinical work within their scope of practice. You need to understand your state laws too. If you have a nurse, they can certainly do more complex care management. They have that clinical triage ability where a medical assistant can only, you know, take direction and relay information. I'm starting to hear more about, you know, why aren't we using community health workers or some of those other kind of more innovative members of your team? And again, not all of your interdisciplinary team has to be employed. Dieticians, pharmacists, social workers, you know, are they employed or are they partners that you're able to work together to meet the needs of your patients? Next slide. So, again, just kind of breaking that down a little bit more, we've provided you some sample job descriptions as well. Care navigators is a term I tend to use broadly. Again, if you're starting small or you have a smaller population, maybe this person is helping to answer the phones and scheduling and then also assisting on visits during certain days of the week or, you know, going through lab results to get those to the providers and different things like that. How can you be nimble with your staff? There's a lot of paperwork. There's a lot of phone calls. Do not put that burden on your provider. What kind of administrative support are you going to do? And then what are you going to outsource? You know, are you going to outsource revenue cycle management or billing or is that a service that through your EHR vendor is, you know, sufficient? Or do you, is it worth it to, you know, contract with a credentialing company in the beginning to do that for you so you're not kind of learning those lessons after the fact? And what other social services and supports do you have available to your patients? Next slide. So, your interdisciplinary team should be patient focused, lean and diverse. What I'll highlight here though is really understand where you're developing those job descriptions and those roles and responsibilities. You know, eliminate redundancies. Who's doing what and is everyone working to the top of their relationship or the top of their scope and are not having multiple roles to solve the same problems? Also thinking when we think about diversity, what kind of community do you serve? You know, are you, do your providers speak the same languages as the highest percentage of your patients? So, really understanding your community and thinking about how you can diversify your team and bring in people with different perspectives and different backgrounds to relate to your patients in your community. Next slide. So, we talked about this too, again, you got to have that business infrastructure too. And it's a worthwhile activity to think about, especially when you're starting out, what do you want to have in house versus what you might outsource in the beginning? We'll dive more into these later, but the other thing, and I touched on a little bit earlier is this, this work is not for everyone. So, what kind of, you know, Dr. Siri highlighted all of the things that providers have to be skilled at. What kind of team members do you want? Driving in the car isn't for everyone. Going into homes in different, in lugging those bags around and things like that isn't going to be everyone for everyone. So, have those probationary periods, take people with you on house calls, really think about who you're trying to hire and what kind of, you know, environment they're going to have to deal with on a day-to-day basis. So, we've given you some provider competencies. I'm going to move this along a little bit here, but take a look at these. There's another tool that we'll share with you later in too about, you know, understanding your providers that are comfortable with complex illness. They may, you know, maybe you need a new wound care or debridement. Maybe you, of course, want that hospice and palliative care background, but you also want someone that's able to manage the whole patient from their primary care perspective, and those might be different providers. Some providers may prefer to just do the symptom management, maybe looking for someone with a different skill set when you expand into home-based primary care. The other thing that we don't really get in medical school is that interpersonal skills, right? So, how are they communicating with patients and families? How are they kind of managing those dynamics and working independently? It can be really lonely for some people to be in the home and be by yourself and not have those team members, you know, that they can just open the office door and call to. Telehealth is certainly given us schools to do that, but understanding this independent work that house call providers really have to do as well as that interpersonal skills we need. So, when we think about kind of where these patients are coming from, we've given you some ideas on where you can start. So, again, can't underestimate the facilities enough. Talk to your local areas, area on aging and senior services communities. They should know if you're providing any sort of community-based services so they can have you as a resource they work with. You should also know about what programs they offer and community care programs that they offer and community care programs and things that you're going to need to help your patients. So, develop those relationships. Even if you're not part of a health system, the ER discharge planners know who those frequent flyers are. They know who the people that they keep seeing in the ER at a hospital are that aren't getting the care that they need. You could consider skilled nursing facilities. Maybe you're even having your physicians just take the medical directorship role for kind of some more stable income. Maybe you do want to go to nursing homes and maybe you don't. So, thinking about kind of what that's going to look like for you. And then community PCPs. Ask them to think about patients that, you know, the family's exhausted, they're sweating when they're coming in, they're in wheelchairs or gurneys, or they're barely able to get in once a year for their medication refills. How can you be a partner for your outpatient PCPs as well? And then how can you get the word out? What kind of community events can you speak at and share or maybe do some even chronic disease education at some of these events? And certainly home health and hospice are going to be one of your biggest referral sources when we think about home-based primary care. You have to have a solution for that after hours. Again, lots of different options here. You can rotate call schedule across your providers. You know, are you going to have just a standard answering service that's going to kind of triage that a little bit or is it going to be a rotating direct line? Think about how you're going to set that up. And then especially during the day too, don't just send every message to the provider. How are you kind of using your team to screen and really make sure that you're meeting the needs of your patient? Could there need be follow-up via telehealth rather than running out to make a house call? And part of the reason you do that, you know, typically on the first visit, your first visit is always going to be your most comprehensive, your longest visit. Are you bringing and creating welcome packets for the patients? Are you going over what your service is and what it's not? And how you're setting up that emergency plan for your patient so they know what to do in a crisis and they still know they're going to have access to medical advice 24-7, which are not going to be there on the weekend thereafter hours. And this is how they can get ahold of qualified team members for those decision advice. But also if you have those conversations early and really take the time explaining your services up front, that's going to kind of eliminate some of those burdens on the back end. So again, this is a very foundational session and we're going to go on a lot more details later, but it's, I know we talked about EHRs a little bit earlier too. I think the problem like Dr. Suri mentioned with hospice EHRs is they're not an ambulatory setting, right? You can't be billing for multiple services. You maybe don't have time tracking ability. Your templates don't have the really domains of that progress note that you need. So I highly recommend you talking to similar organizations. What EHRs are they using? Do they have a build that they could recommend that have already been customized? NPHI has a great community of providers. Are you really exploring all your options and investing in this? Because it's quite a process to have to switch EMRs and it's frustrating for providers. It's time consuming. It's expensive. So really be thoughtful about whatever technology you do go with and make sure it kind of has those, has the ambulatory progress note build. You're able to do all the things that you need to do. And you're also able to kind of use it in a meaningful way to tell that story and have reporting and time tracking capabilities and things like that. The other thing you have to think about is connectivity, right? So most household practices are going to have to invest in some sort of VPN or mobile broadband cards in the laptops and iPads so that they have reliable connectivity in different areas. You also want to have a backup plan. I know some practices that like to print kind of an ABS or some sort of face sheet so that if you, for whatever reason, it's just a bad day or you go into a new area and you have no access, you still have your patient's medication list and some basic information that you can work off of to still have a meaningful visit. If worst case, the technology does not work. So what does that downtime plan look like? We'll talk more about templates too, but really understanding the different domains, what screenings do you want to start with? What is your new patient progress note versus your follow-up versus your transitional care progress note look like? How are you setting those things up to be efficient and not overburdening the number of clicks for the visit? And how can we really make the most of those? Smart phrases and macros will be your best friend. But understanding too what's out there, this particular link is improvehousecalls.org. There's the National Home-Based Primary Care Learning Network that has done a lot of work around standardization of quality metrics, and they have different opportunities to participate in the learning network and kind of learn from quality improvement of others. So really be thinking about this and also comparing what metrics you're seeing in different value-based care models, different kind of things that you may want to be participating in so that the screenings and the assessments and the metrics that you are tracking are really meaningful and you're kind of working towards that partnership relationship. So again, just food for thought with some of these examples. I'm going to skip this slide because we'll talk more about CCM later on, but I think that's really the difference. Dr. Siri mentioned advanced care planning. Again, this from a billing perspective is a fee-for-service billing opportunity. You're having these conversations, but are you getting paid when you're spending 16 minutes face-to-face with a patient or caregiver? And right now, this can be done telehealth too. Do you know what that documentation needs to look like? And are you actually customizing it enough? So understanding and exploring these EHR capabilities as well. Appointment prioritization. This is probably the biggest pain point that we see in household practices. You're going to be proactively planning schedules based on your patient's need and geography. You want to see them in one month, three months. When are you in that area next? But nothing ever goes according to plan. You need to have strategies in place for how you're going to deal with those acute and urgent same-day add-on requests or when your patient needs care before that next follow-up visit. So when you're thinking about your productivity standards and your scheduling staff is scheduling future appointments far out, do you have a limit that you're keeping open until the day before or the week of so that you have that flexibility? I know some practices that will have a provider on call per region that has a little lighter schedule that day, so they're able to help out patients. You can also really train up your staff on how they're triaging, what the patient's need is. Are they saying they need appointments, but maybe after a nurse talks to them or a telehealth visit, you're really able to kind of manage their emergent need until you're in the area next. So really be thoughtful about appointment prioritization, what's their acute urgent visit strategies, and how is the entire staff kind of aware of that so that they're all getting the information they need, working together before you just try and add that patient onto your schedule. So with that, if we can, any immediate questions? We're going to be breaking for lunch here. I know virtual setting can be hard. Get up, stretch, try and walk around. Well, you're going to hear a lot from me today, so be interactive in the chat and I'll try and be as engaging as I can as we all engage virtually today. Yeah, thank you so much, Brianna. I think what we heard in that session was really some foundational things that will lay some groundwork for Brianna to dive a little bit deeper into these things. But if there are any immediate questions, you can feel free to raise your hand, post things in the chat. And I know we are due for a lunch break, right? Everybody needs about 30 minutes. Get up, get something to eat, walk around. We've got more this afternoon, so we will rejoin back here at one o'clock central. But I encourage you to stay logged into Zoom and just close your camera and your microphone, and we'll see you in about 30 minutes. Thank you. Oh, there's our recording. Okay, so I hope you were able to get some lunch, bring some snacks back to your office. And because we are about to dig into some of the details that you've been looking for on coding, documentation, and billing. And so with that, I'll turn it over to Brianna. Thanks, Melissa. Welcome back, everyone. Usually I have to do coding before lunch, and that's always very painful for people. So hopefully you're a little more energized now as we are moving into our coding talk. So getting paid for what you do, you know, a little disclaimer to, you know, your organization may have more strict compliance policies. You should always, especially for those of kind of revenue cycle managers and people in that type role, follow your local MAC, your local Medicare administrative contractor for policy guidance that they may be enforcing. I'm not going to tell you anything that's not a federal condition of Medicare program and documentation guidelines, but always important to understand kind of those other caveats specific to your local region. So we can move on from there. We're going to talk about kind of what I call the core principles of documentation. And I always like to say, not telling you to do more documentation or I'm not telling you you have to do X, Y, and Z in order to bill for certain services. I'm encouraging you to document in a way that's meaningful and strategic to get paid for the work that you're already doing. And how can we minimize documentation burden in some places to increase efficiency? And what are those kind of core principles that really need to be there? Where should you be spending time customizing documentation? Templates and all of that is great. We want to use them. We want to do that. But your documentation shouldn't be so templated or full of so many smart phrases that you're losing that personal touch that what's really going on with the patient on each individual visit. So next slide. These three golden rules are probably things you've heard preached to kind of over the years. I always change the first one. I don't like saying if it wasn't documented, it doesn't count. But rather, if it wasn't documented, we can't credit you for that as an auditor. We can't prove that that conversation occurred. There's nothing for even consulting providers to go back to if you really weren't elaborating on what happened during each visit and throughout the patient's care plan. So it's really important to make sure that you're accurately reflecting what went on, what concerns, what changes and conditions throughout the care plan and throughout each of the visits. I also, at the same time, will always be, go back, be the biggest advocate for more words does not mean better documentation. I'm a big fan of bulleted documentation. Where can we take things in a template that don't need to be there out? And where can we spend more time on the meat of the documentation? And then cloning, the formal definition for cloning is when two medical record entries look exactly the same or very similar to the previous entry. Where that gets to be problematic is if you're copying and pasting or using those EMR tools to pull things over and then not updating it, it'll start to conflict each other. So, you know, you may be pulling information over on a wound that no longer exists or you told me in the HPI was healed. So you have to be really careful about how we use our EMR and make sure that you're updating documentation for each unique visit. So these are the E&M requirements that we're going to go over and then have to be there every time. I'll use this slide as a caveat too, is we're focusing on the here and now. These documentation guidelines have been around since the 90s. Some of you may know that the documentation E&M coding guidelines changed in 2020 for office visits codes. They didn't change for the rest of us. AMA and CPT, AMA governs CPT and the codes and the documentation guidelines has proposed changes to this for 2023. You're always going to have to have these core elements, but what they're proposing to change in 2023 is that just the medical decision making or just certain aspects of how you spend your time for your visit will be how you code the encounter. I am not teaching that today because number one, we don't have the Medicare final rule that'll come out in November of this year sometime. We want to make sure that Medicare doesn't disagree with AMA and CPT or create any new crazy G codes or something. So this is what we're focusing on the here and now. These E&M requirements are always going to be there, but if you're not following the potential 2023 E&M changes, I wanted to use this slide just as a caveat to make sure that you're following that. And again, as long as Medicare is agreeing their policy and documentation guidelines with what AMA and CPT is proposing, you can start strategizing on how you're going to prepare for that now. The other kind of myth that we see a lot in house calls, again, I talked about how the patient doesn't need to meet the skilled home health homebound definition. You used to have extra documentation that you had to include in every home-based primary care visit or every house call visit saying that the patient required a home visit because or in lieu of an office visit. They did change that in 2019. As long as the patient's encounter is medically necessary, as long as you can prove the point for why the patient needed the care, the decision to see the patient in the home is left to the patient and the provider. So, if you're having these extra statements just because Medicare used to require it, those are kind of those things we can look to take out of our documentation that are no longer required. Medical necessity can always be a bit nebulous. This is kind of really when I'm saying think about what matters and as providers, what can you document? Why did you need to see the patient that day? What was going on with them right there and then in that moment, how have they been managing their diseases and are you telling me that? Are you using enough descriptive words that I can tell what the, you know, if it was a problem that was exacerbated or was worsening or, you know, their BP has really been fluctuating a lot. So, can I tell the status of their chronic diseases? In the HPI, I want to understand that from a patient and caregiver's perspective and the assessment and plan, I want your clinical judgment and interpretation as the provider. Can I really understand where they're at and what you're telling them to do from a care planning perspective? Don't miss out on making sure that you're documenting specifically what discussions were being had, what things you might not be prescribing but you're considering or additional records or people that you've had to talk to to care for the patient. All of that is going to go into the medical decision making. But again, if you don't tell me that medical record, then I can't understand and validate that that was done. Medication reconciliation. Go back one, please. You know, kind of the CPM, the days of continued present management or stable continue are gone, especially from an HCC diagnosis validation standpoint. We really need to understand what medications is the patient on? What are you addressing? What is the specific care plan? How are they going to manage their diabetes, hypertension, heart failure from now until the next visit? Be specific and customize your treatment plan and your treatment options. This is where it matters to spend a little bit more time so that if I'm just looking at the medical record, that paper, it's really reflecting how sick the patient is and it's really reflecting what care went on during that day. The other thing to keep in mind, and there's some, you know, practice operations, you know, things that you can put in place to monitor how quickly are your providers finishing their documentation from when they see the patient to when they sign the note to when that claim gets out the door. This is incredibly important from a revenue cycle standpoint as well. If you're having a significant delay on when you're getting payment, just because your providers may not be as timely with signing and getting those things in. And if it is really taking them a long time, there's probably a reason behind that. So what, maybe it's a template issue, maybe it's a training issue, you know, what can you do to maximize that provider's time so they don't feel like they have to have these big lag times between documentation. Medicare at the federal level tells us it has to be done as soon as practical after the encounter. Again, your specific max, sometimes they even put more specific timeframes on that, but the bottom line is that progress note should be completed and signed as soon as possible. And you want to try and aim for that 72 hour window of when that claim is getting out the door so that you're getting payment. Don't hold charges till the end of the month either. There's really no reason for that unless it's like a, you know, chronic care management where it's adding up time throughout the entire month, which we'll talk about, but make sure that you have a good revenue cycle process and you're getting those claims out the door so they can get paid in a timely manner. So what are some things that CMS looks for? What are some things that are kind of heavily audited that we know we have to be on the lookout for? Again, I talked about medical necessity. That's really just telling your patient's story. Do I understand why you needed to be there in the home? Do I understand what you did? And do I understand how sick the patient was? As long as you do those things, you'll never really have to worry about that. Just seeing a patient every month, just see the patient every month, if you can't make that case, it's not gonna stand up when Medicare is looking at it. We have more flexibility, again, some of these other models and state and facility regulations. But if you are doing procedures on the same day, you have to make the case for it. So you can always bill for these things together when they're appropriate and they're separate and distinct with modifier 25. But for example, if the patient needs a joint injection and you happen to be in the area that day, so you add them on at the end of the day and that's really all you focus on, but you try and bill for both just because you were there, well, that's not really gonna stand up. If you really took the time to address something unrelated to the arthritis for the reason they needed that joint injection, that's when you can bill for both. But it also depends on why you're telling me you're seeing the patient and why you're doing all of those things. Again, cloning, the problem with that is it jeopardizes the integrity of the medical record. So when we think about making sure that our documentation is consistent and concise, when I used to do a lot of auditing, I would run into kind of, I'd have to reread notes because I would get confused because they would be telling me one problem's in this state and then there'd be something completely different. All of a sudden, the patient has a wound in the assessment and plan when the physical exam and everything else had told me not. So just be really careful, do some internal auditing to make sure you're not accidentally pulling things into your documentation that you might not even need to. Again, so we can debate all day about EMRs, friends and foes. What I'll say with this is don't overburden and don't put anything into your template that doesn't absolutely need to be there and look for functionality within your EHR where you can not have certain things in certain notes or have different note templates for the visit type that's really tailored to what that patient's going to need. So be tactical in how you're using these tools and make sure we're not overburdening our providers. You're not gonna be doing every screening and every assessment every time. So how can you make sure you can pull those in only when they're relevant and appropriate? There's different places of service. Again, a lot of this is just gonna be handled on the backend billing side. The home visit CPT codes are when you're seeing a patient in a private residence where that's considered their home or an independent living area that has no group support or kind of, you know, they're not getting assistance from the facility staff with medications and personal care and things like that. Assisted living and group homes right now, and we're giving you all of these codes in future slides are billed with what's called the domiciliary CPT code range so important to understand if you are going into facilities requirements are the same, just different CPT codes. Medicare is proposing to combine that or not Medicare, AMA and CPT are proposing to combine that next year. So another thing to keep an eye out in 2023. You have to understand modifiers, you know, 25, again, you're billing in the fee-for-service world when you're billing for two different types of services or lots of different types of services and you wanna get paid for both, right? So if we're doing an annual wellness visit and we're managing chronic diseases, so we bill for an ENF or we're doing advanced care planning and our comprehensive visit, you need to understand from a modifier perspective when that can get billed. If you're doing, again, joint injections and multiple different joints or things like that, GW and GB is probably the most relevant to what we all do. So you have the choice to continue providing primary care services or palliative care or primary care services to your patients who are enrolled in hospice, but you will never get paid as a part fee service or for those primary care services if you don't have a modifier. So if you're seeing a patient that was a separate entity within the hospice and it's not related to their hospital terminal diagnosis, that's when our providers are using GW. If you are the primary practitioner employed by the hospice and are continuing those services or seeing a patient related to their terminal disease, that's when you're using GB. But if you're starting to see denials for your hospice patients when you're providing home-based primary care services, it's probably as simple as you not having the appropriate modifier. So telehealth is a huge one. Again, the pandemic has totally opened up the doors for how we're using that. Medicare uses modifier 95. Again, we're gonna have some new modifiers and some changing things that we're gonna have to keep an eye on in the world of telehealth. So just make sure if it's not you, this is something your revenue cycle system should be doing. A lot of EMRs offer those kinds of services. Are you getting reports and you're understanding if you're making denials? Is it something as simple as a modifier fix? The other thing about making the case from intake and kind of being tactical in the comments and the appointment reasons is making sure that your staff who's scheduling patients really understands what's the patient's need, where are they calling from and what kind of facility they live in. This is probably the biggest impact. Are they assuming it's assisted living just because it's a senior building? So really trying to understand what is the patient's place of service, if you will, or what is the patient's residence and what kind of coding impact does that have is important. This is probably one of the most common questions that I get is how often can I see my patients or what's Medicare's visit frequency limitations? So there's nothing at the federal level. Every visit has to be medically necessary and how often you see the patient should be a clinical judgment by your provider that's determined on a patient by patient basis. So what I mean by that is we know that seeing your patients more often, especially when they're chronically ill is best medicine, but you can't just have a blanket policy in place where you're gonna tell your scheduling staff to schedule all patients every four weeks, especially for those pleasantly stable dementia patients. It's not gonna hold up. So make sure that you're customizing the visit frequency based on the patient and the provider's clinical judgment. And then there are, you can use tools in the background to risk stratify patients or determine acuity and kind of guide that decision. But what you don't wanna do and have documented is some sort of blanket policy for all your patients. The medical necessity and the medical needs of each individual patients based on the provider's clinical judgment should be driving the care plan and driving how often these patients are being seen. So when we think about chief complaint, I mentioned that, you know, in the E&M guidelines, it says you always have to have a medical reason for the visit. It can't just say new patient visit or follow up visit or a palliative care consult even. That doesn't tell me a medical reason for the visit. What conditions are you gonna be managing? Are there acute complaints? Be specific. This is a simple, easy change that you can make to your documentation. Are you telling me what the medical need or maybe it's family, you know, combination of medical and social needs that you're seeing the patient for? And avoid those generalized terms like new patient, follow up, palliative care consult. Well, why were you consulted in the first place? Why are you seeing the patient? When we think about HPI, I mentioned to you bulleted documentation. So you have two options. In home-based primary care, you know, we're trying to get that to that status of three chronic conditions for that expanded HPI or, you know, those four or more individual characteristics of an acute problem. I would say from an efficiency standpoint, what I'll see in follow-ups is the same synopsis, that same kind of long history of what the patient's medical, every medical condition history was, how they came to your program, when they stopped going out. You don't need that in every note. So it shouldn't be a long, you know, medical history paragraph, if you will, like we commonly see in documentation for every visit. I want to understand what the patient's status is on that date of service. If you tell me the status of three chronic conditions, even in a bulleted form, that'll always get you extended HPI credit. Or if you're symptom managing, are you really describing that problem? So radiating low back pain tells me two things. It tells me the type of pain and the location. The patient reports the pain as a seven out of 10. That tells me the severity. When did the pain start? Two days ago. Have they tried anything to make it better or worse? Tylenol with no relief. That's an extended HPI in just one sentence. So I think the pitfall that I see is a lot of other great information that's not actually HPI when we're thinking about documentation. So this is kind of where we want to strive to get to. Is it meaningful? Is it focused on what's going on with the patient on that date of service? Review of systems, again, a template thing. You don't need to have all those 10 to 14, negative, negative, negative every single time. Document anything that's positive. You know, if it's an abnormal response or if it's a pertinent negative response. And then you can always say all of their systems are reviewed in negative. And that could be something that is appropriate to build into your template when you're doing a comprehensive review of systems, but you're just documenting what's abnormal or you're just documenting what's, you know, what's the abnormal finding or the positive response that you need to focus on. Past family and social history. Again, you have to have this for new patient encounters. So your follow-up visits, you could have two of the three, or you could mark, you know, the family history is reviewed, things like that. But from an E&M perspective, if you're missing a family history on a new patient, it will always drop the level of service. So again, making sure that we're documenting this on intake, using your medical assistance to pre-populate charts so that this information gets in there and you're able to document all three things, especially during the initial visit or those new patient encounters. Physical exam. Again, these patients are sick. They have advanced illness or they have multiple chronic conditions. You know, just understanding, you know, comprehensive exam is eight organ systems, but making sure that you're setting up, I'm a fan of organ systems rather than body areas and template. How can you combine body or area finding with a system to make documentation a little bit more efficient? But the physical exam, again, it's making sure that you're documenting it appropriately and not copying and pasting every time so that, you know, details aren't updated that aren't accurate for that encounter. So we're gonna talk a little bit through medical decision-making, and these are the three things we look for, and then I'm gonna kind of show you how an auditor would score this so you can think about how you're documenting these things in real time. So first off, we need to understand, what are the, how many diagnoses or medical problems are you meaningfully considering during that visit, right? Everything is coded at the visit level. What else did you have to do for the patient? What's the amount of complexity of labs and data, things that you had to review, and then what's the overall level of risk? We can go to the next slide. So when we're first thinking about MDM, and again, this is how I'm scoring it from an audit perspective, you don't need to know these points, if you will, or these things, but especially if you're a provider, if I'm looking at your assessment and plan, this is where I'm saying, are you using those descriptive status words? That's an easy change, just adding a couple more words to your documentation. Can I tell that the diagnosis listed, if it's a new problem for the patient or if it's a chronic problem, and is it stable or working? Really important because it matters for medical decision-making. I also, I'm gonna use this slide to highlight that the patient's problem, you know, problem-less should not be the assessment and plan, right? If you're not meaningfully assessing all of those chronic conditions, save yourself the time and just focus on what really matters to that encounter. You're gonna have a lot more flexibility with documentation and value-based care, but it should always be meaningful clinical documentation that's addressing the problems at hand and really giving that synopsis. Next slide. This is kind of where I say, again, if it doesn't document it, you can't validate it, just give yourself credit for all the work you're doing. What lab tests are you ordering or reviewing? Are you having to consider diagnostics, especially if they just came out of the hospital? Were you reviewing ultrasounds and test x-rays or echocardiograms, things like that? Did you have to consult with another provider, especially during palliative care? You know, are you talking to the PCP or the referring provider about the patient? Making sure you make a note within the progress note because we care about that for medical decision-making. Reviewing and summarizing own records. And again, if you have to even talk to the home health nurse or someone else, make sure that that note is everything you had to do to make your decisions during that visit for the patient are documented. Next slide. And then finally, this is just the CPT table of risk. This is the third element of medical decision-making. So we talked about the number of diagnoses or problems you're addressing, that data and those other elements that make the work you have to do. And then this is just overall risk. Almost all of our patients are at moderate. If any of these bullets, just one in any row to get to that level of risk, two or more stable chronic illness, one or more exacerbated problems. High is really when that patient's probably, you're making that decision, do they need hospital level care or not? But again, if you're not being descriptive in your documentation, it's not gonna be a really accurate assessment of where we're at when we think about the overall level of risk and complications for our patients. Next slide. So again, medical decision-making, this is an audit tool kind of format. I think it just helps providers wrap their head around why it's important to use those descriptive status words, make those couple comments or statements about all the work that you're doing and really make sure that you're telling that patient's story of complexity is a two out of three mentality in scoring medical decision-making. But you should be comfortable with this so you're not building all this up. Talk about time-based documentation and when that's appropriate, but really understanding how to reflect medical decision-making in your documentation. These are just kind of some examples of kind of putting it all together. So moderate medical decision-making, three stable problems, and you've continued or prescribed a prescription. That would be moderate because it's two out of three. High medical decision-making, maybe one of the problems was worsening or it was an exacerbation. And then there was one new problem that was pretty straightforward. The overall level of risk is high because of all the things and the factors and the complications and the testing that you were doing for that exacerbated problem. So giving you some different examples on how the three aspects that we look for for MDM kind of get tied all together and kind of what you need to do to tell that story. MEAT. So many of you are familiar with the SOAP acronym when we think of documentation. MEAT is a lot more relevant to HCC coding and validating the diagnoses that you're saying that your patients have, which we have a full session on that. But this is an easier way to think about that assessment and plan too. How are you monitoring the problem? What are the signs and symptoms that you should be using each diagnosis that you're coding? How are you evaluating that? You know, assessing and addressing, tell me that status word, you as the provider, what is the clinical indication or the clinical status of their disease? And then what is your specific care and treatment plan? How are you treating that? What, you know, maybe it's your medications, maybe it's monitoring, maybe they need to have some more discussions with the family to make that treatment decision. But just make sure that you're, for each diagnosis, you're gonna list your assessment and plan. You can, you know, summarize how you're monitoring and evaluating, assessing and addressing and treating each problem. And the patient's assessment and plan is, again, it's not the problem list. It doesn't have to be every diagnosis every time unless you're actually meaningfully treating them all. Again, it should paint the picture of their health. You wanna be able to tell those kinds of disease. And also prioritizing. So sometimes it's just easier to click on the first diagnosis that pop up for the patient. And in palliative care, what can be really devastating, and Dr. Suri mentioned this a little bit earlier, but if you're coding signs and symptoms rather than the chronic disease, first off, that's not an HCC score and value-based care. That's not gonna have the health plan or your partner will really get you in the right payment tier for getting paid for complex patients. What symptom of the chronic disease does it relate to? So be specific. Is their leg swelling really due to CHF? Or is there pain due to cancer? Or is their shortness of breath really a COPD exacerbation? You wanna be focusing on coding that chronic condition. So again, just that's a little tangent about ICD-10 coding, but that's another important thing to keep in mind. That can be a little bit of a culture shift, especially if you come from inpatient palliative care, or because there's multiple different providers seeing patients on a day, it might've been a little different in the inpatient setting. In the outpatient setting, we're always coding the confirmed chronic condition, so the home outpatient setting, and the symptoms are kind of elaborated in words, if you will. So focus on the chronic disease score. This is the AMA's definition of what it means to have a problem addressed. So, again, meaningful documentation, you're not just referring to a consulting provider, you're the one responsible for caring for that patient. Next slide. Making sure that your treatment options are specific, and the referrals that you're making are validated. So when you're referring a patient to Home Health Services, you're referring them to the specialist. Again, this is what you need to do to get those services covered. Those clear instructions and therapy should be reflected within the medical record. I really like this note, and, or this article, I apologize. So this was a prescription for note bloat is the title of the article. It talks about some of the pitfalls with documentation, and it comes more from the inpatient hospitalist world, but what are the best practices? How can we make the most of the documentation? We talk about it being up-to-date, accurate, and thorough, useful, organized, still comprehensive in explaining the patient's ailments and where they're at in their disease, but it's still succinct. It's easy to follow. It's consistent. You're not having conflicting documentation. I will say, especially when you're moving into value-based care, this is a culture shift for how elaborate they may have to be. Providers may be used to being in their documentation. So how can you think about these things and even kind of peer audit each other and think about what's your recipe for documentation? How can you make sure these things are happening and how can we make sure everything we're asking our providers to do is necessary and consistent? So we do have options. It's not wrong to build on time, but I will say a pitfall from, especially when I have worked with hospice and palliative care practices, is if you're billing 100% of your encounters or 100% of your visits on time, you're leaving revenue on the table because these patients are complex and there's a lot of medical decision-making that should be considered. When the visit really is focused on counseling and coordination of care, or really those non-medical aspects of the visit, that is when it might make the most sense to build on time. But really be thoughtful with your time statements. I need three things to tell me that you can build on time. I need the total exact minutes spent that greater than 50% was dominated by counseling or coordination of care. And then you need to customize the time statement. It should not be the same for every provider. So actually, if you go to the next slide, I think I gave you some examples. Here are some start of a smart phrase or a template that you could use for time-based documentation, but do not forget to customize it. What kind of counseling occurred? What specifically did you counsel the patient or educate the patient on? What kind of care coordination efforts were occurring? You need to be specific. And if all of these three things are not there or they're not customized, then it would not be considered a compliance. When it might make the most sense, again, when you're making that decision as a provider, am I building on medical decision-making? Am I building really on time? If you were there for a really long time, you can probably always make the case for why time is appropriate because that may be when we're considering prologue services and it's important to get still on time or when those other non-medical factors really dominate the visit. But again, make sure provider's comfortable with both so they can fill on E and M and medical decision-making and time, understand when it's most advantageous for them to do one or the other. So these next couple of slides are just for your reference. So these are the CPT codes for the home visits. This slide is new patients. The next slide is established patients. Create little reference sheets for your providers, especially if they're not used to being cared for in the home, understand what the fee schedule is for these different and the time threshold so that when you're there for a 90-minute visit or longer than that, you know how to get paid for it. So if you go two slides up, so again, these are more just for your reference. These are the home visits for follow-up visits or established patient visits. We only have four levels of service and then here is when you're seeing those patients in the assisted living or in that group home environment, those domiciliary codes. Again, some of that is determining on how you see the patient. I can stop for a minute and try and plug a headset in. Sound is getting a little bit choppy. Thanks, Brianna. I was gonna have you wait till the next time, till the next presentation, but yeah, it is getting a little bit worse. So thank you. And this is just, while Brianna's getting that set up, this is all really good, complex information that she's sharing. So if you have questions, don't hesitate to put those in the chat. Thank you, Melissa. Can you guys hear me better now? Yes. Okay, all right. Thank you for whoever put that in the chat. So again, these are references for your provider so you understand the different codes that you should be using at different times. Next slide, please. All right, I wanna stop here for a little bit of discussion. And like I said, I know it's hard to listen to a lot of complex information. So if you have coding conundrums or challenges you wanna talk through, we have some time to do that in this session. Again, these are all fee-for-service coding opportunities. You're always gonna have some percentage of fee-for-service, realistically, maybe unless you're really advanced in value-based care. So how do you know what all of these tools in your toolbox are? And how do your providers know these are all of the things that align with the model of care that we're providing in the home and how are we getting paid for that? So Dr. Chang, I wanted to invite you to kind of talk about as you're kind of in the transition of fee-for-service to value-based care, what kind of services are you most commonly billing for in your practice besides just the visit itself? Well, thank you, Brianna. I think I will, if I can just take a minute here, I would like to make four comments based on what you have discussed and I think you're gonna discuss it more later on. Early in my career, when I was much younger and much less mature in my thinking, I often said to myself, this is so boring. Why are you boring me with billing and coding and stuff like that? I rather much deal with the more beautiful, elegant, exciting thing of medical management, right? Of a complex patient. That is why I went to school and learn all that stuff. But as many of you know, the saying, no money, no mission, right? So as I gotten more mature and started to understand more of the importance of the dollar, I just can't take Cinderella to the ball. I do have to bring the two less attractive, maybe a little ornery, sisters of billing and coding to the ball because without them, I can't tell the story. I need to be able to tell the story about my patients, their illness and so on. So I think that's the first thing. I constantly have to kind of fight the resistance. I don't wanna learn this. It is important. The other is that have templates to cut down, what two things, have templates to cut down on keystrokes. We all try to do that. But I think templates can also help you optimize the care that you're delivering and meet the meet criteria that Brianna was talking about. I've often said to learners, and when I have residents rotating from Northwestern with me and so on, I said, good medical care is good palliative care. I am a little uneasy about that artificial divide there between primary and palliative, right? So my point is, for example, if you're taking care of patients with heart failure, we'll talk about that tomorrow. You can have a template that says CHF condition is stable or declining or whatnot, and then list a couple of things that you really need to do. Like, did you review the labs? Labs reviewed. Did you order labs? Labs ordered. Or is this patient on appropriate heart failure medications? And you can list them and we'll talk about them tomorrow, right? The four pillars of heart failure, beta blockers, your ARNI or your ACEs or ARBs, your MRAs, and now your SGLT2 inhibitors. Put that in your template. That gives you meet documentation, plus it gives you good clinical care for your patients. So template's important. Resist, oh, you know, I've cloned before. I know this is confession, right? So sorry. So please resist the temptation of cloning. Sometime when I read my previous note that I cloned, and I'm like going, oh, I'm just so embarrassed that I wrote that, you know? Anyways, try to resist the temptation of cloning. And my final comment is be on the lookout, as Brianna alluded to, the 2023 change that will be coming in terms of new billing and coding guidelines, if you will. It's gonna be based more on complexity of the condition and the data to be reviewed, and also the risk of exacerbation or deterioration, and less focus on all these bullet points and so on. So that's to be determined. Just keep that in the back of your mind as this change. For us, transitioning from fee-for-service to value-based care, it's slow process with Northwestern. And I think I'll just summarize by saying this. The focus for us, and I just had several meetings with Northwestern this week, it's on HCC coding. Proper coding, telling the payers, telling the payers how sick your patients are. They don't just have COPD. They have chronic respiratory failure with hypoxemia and hypercarbia, all right? You need to be able to tell them that so that you can get the reimbursement and the risk score that you, not that you deserve, that you're managing. So it's really important. So I think that's one thing that we are really focusing on as a health system is really improving our documentation and our HCC capturing. And I'll just end my comments there. Yeah, thanks, Dr. Cheng. I think all kind of just why do providers care about this? Why is it important? How is it important for practice sustainability and kind of be champions? We talked about having that program champion. If your clinical leadership or your physician or nurse practitioner champion is not really also preaching this to your providers, in addition to your kind of coding expertise or your administrative expertise, they're gonna be less bought into why this is important. So E&M services, that's why we just spent some time talking about that. That's your bread and butter. It's really important to understand what level of service you're billing at. Again, these are fee-for-service opportunities for you to know about. And we've given you resources that go over into all more detail. I'm gonna talk specifically about a couple of them in the next coming slides that generally are the biggest revenue impact for home-based primary care, but transitional care management. So it's a different CPT code when you're seeing a post-hospital patient, inpatient or observation hospital stay. You have to see them within seven to 14 calendar days. There has to be that phone call or what CMS calls interactive communication with a patient within two business days. So you need to kind of check on them. Do they have their medications? Are they safe at home? Are you going over that information? Then you're doing that post-discharge visit. It's a lot higher reimbursement than an E&M code. So understanding when it makes sense to bill the TCM code rather than just your follow-up visit. We'll talk about chronic care management. Care plan oversight is the other opportunity for those of you doing home-based primary care that are managing patients on hospice. And you're spending 30 minutes at least per calendar month doing that. There's an opportunity there. Also just for signing and being the ordering and overseeing provider for home health. So GEO 180 and those GEO 179 codes. Again, we're giving you a lot more detail in a handout on all of these. But understanding when you sign that first 85, when you first order that home health episode, if you're the ordering and overseeing provider, you can bill for that. And when you recertify the patient for home health services, once every 60 days, you can bill for that as well. We talked about advanced care planning. Prolonged services, that's why those time thresholds that I gave you in those grids are important. So if you're spending 31 minutes or more, if you're exceeding that time threshold by 30 minutes, then you should be billing for the extra time that you spend with your patients. So really important, again, build these all into that charge capture favorites for your providers so they can easily find these codes and they know when to do it. Give them cheat sheets, give them examples. These are when you would bill these types of services. Make it really easy for them to maximize revenue for the work they're already doing. Like Dr. Chang said, make it as easy as you can from templates. The cognitive assessment and care plan visit, that's if you have a patient with dementia or cognitive impairment where you're really just doing a visit focused on that. It's a very targeted visit where you're assessing their memory or their cognitive impairment with some sort of standardized tool. You're developing a cognitive specific care plan and then you're care planning and giving the caregiver resources. That code also pays a lot more. It's not a time-based code. CMS does expect it to be a pretty extensive visit. They say about 50 minutes, but you don't have to have time in that type of visit. Annual wellness visits can be a great opportunity for HCCs and quality captures and kind of just using those visits efficiently and then not forgetting to bill for smoking cessation when it's four or more minutes or things like that. All of these guidelines are expanded on in a handout for you all, and we're gonna talk a little bit more about a couple of them, but Dr. Chang, comments or thoughts you would add? Yeah, Brianna, for us, it's an awkward time. We got one foot in two canoes, right? We're trying to go upstream with a value-based payment and at the same time in the canoe of fee-for-service. Again, we're not, as Brianna said, we're not asking you to document more. We're simply asking you to think about having the right documentation for the work that you are already doing, like advanced care planning. Use the advantage of, not the advantage, use the opportunity to bill for that because we do a lot of ACP talk at our visits. So now there's an opportunity to bill for that. The other one that we've been using is the prolonged services. I'm sure, and I'm not the only one, when we're out to see a new patient, there is a stack of an inch and a half of old records from their doctor from Florida that I need to review. You can document in your chart, again, having a template, highlighting what you review, what the labs or the x-rays and et cetera. And then the time that you spent for the, you can bill for that. That's a value add or your dollar add to your service as well. Annual wellness visit, there's a big push in the health system for that. In addition to your E&M, you can do your annual wellness visit and add a code to that as well. Again, think about opportunities to capture more revenue, especially if like me, you're still under fee for service, getting credit for the work that you're doing. And then on the other side, having a template so that you are not creating a lot of keystrokes to get what you need to get done done. Thanks, Dr. Cheng. And the other thing we can move on and we're gonna talk a little bit about chronic care management, but understand depending on the type of value-based arrangement you may be in, sometimes there's carve outs or certain services that may be bundled and certain ones that are not, but you could still get paid for separately at a fee for service. So understanding kind of what your payment arrangement is and what your opportunity is. I'm gonna talk about chronic care management from a fee for service billing perspective. If you are in a fully capitated or fully value-based model and you're trying to start home-based primary care, I would say use these clinical guiding principles to kind of the shift or that culture shift from a palliative consultative service to how you're managing patients on a care plan for all of their chronic diseases. There is another opportunity to called principal care management, where if you're really only doing palliative care, it's gonna be very similar guidelines that we're gonna go through, but it's for managing a single high-risk disease. But the reason we're gonna spend a little bit of time talking about chronic care management is because a lot of people ask in fee for service, how do I get paid for all the non face-to-face work, all the phone calls, all of that, the time spending managing these patients in between. And I think chronic care management is our best fee for service revenue opportunity for that right now. So it is a time-based service. This is where when you're exploring EMRs, having some way to systemically track time throughout the month, again, these are not visits, these are phone calls, non face-to-face care management, things that occur. To meet Medicare's definition, they do have to have two or more chronic conditions that put them at risk. You do have to create and monitor an electronic comprehensive care plan and at least 20 minutes per month. And there's different codes depending on if it's your provider's time or if it's combined time. This might also be how you afford an RN. If you're in fee for service too, is getting billed for some of your clinical staff time as well. So here's all of the requirements for chronic care management. It may seem like a lot, but we're gonna kind of digest this. So for new patients or patients you haven't seen within 12 months, you have to enroll them in CCM as part of a face-to-face visit. So make this part of your process for new patients. Talking about chronic care management, having that verbal or electronic consent signed is part of the process. It can be just a verbal consent for CCM or you could have a written form. Either is fine, but develop your consent template and process for that. You do have to use a certified EHR vendor. That's why, again, if you're exploring a new EMR because you're a hospice organization expanding into more palliative and home-based primary care, this is why it's worth it. CMS doesn't feel that non-certified EHRs have the technology and the interoperability requirements they're looking for. So that's why that's in here. 24-7 access, designated care team member. They can reach you when they need to after hours and they have a longitudinal relationship with your team or your providers. We'll talk about the care plan and all these other things you're doing. You're managing their transitions. You're offering enhanced communication opportunities either through a portal, secure email, telehealth, all of those kinds of things. And you're partnering with home and community-based services to care for your patients. Next slide. We've given you an example care plan. Again, this does have to be electronic. So it does need to be built into your EMR and it can't just be in your progress notes. So there does have to be a separate, distinct, comprehensive electronic care plan to bill for CCM. This is what Medicare recommends. So anytime Medicare is recommending something, I would build that into my process of what elements need to be in that care plan. When you're longitudinally managing patients, really thinking more long-term about their disease, again, it's gonna be a little bit of a mindset shift. Next slide. So these are the codes. So I recommend traditional CCM if you're trying to get paid for both your clinical staff time and your providers. So 20 minutes per calendar month is at 99490. You can bill up to 60 minutes per calendar month. Each additional 20 minutes is billed with that 99439 code. That really makes a difference in your bottom line. It's really getting you paid for all that non-face-to-face work that you're doing and managing patients' kind of care plan over time. If you're a smaller practice and really don't have a lot of staff yet, administrative staff time cannot be counted towards this. So it has to be clinical staff. It has to meet CPT's definition of a clinical staff member. But if your providers really are doing all of the work, it would pay more to bill for what I call the provider CCM codes or the 99491 or 99437. It has to be at least 30 minutes per calendar month for the first code for that. And it has to be all a qualified billing practitioner's time. And then finally, complex CCM. Actually, if you do the math, it pays a few dollars more to bill traditional CCM than complex CCM. And then you don't have to meet the higher bar of complex care planning, exacerbations, really complex things going on and changes to the patient's care plan. So codes to know about, especially to get started. If you are enrolling and spending that care planning during an initial visit, there is a code for that. I'm gonna move us along here a little bit. Sorry, next slide. This is kind of, if we're tying this all together, what do you need to build for or plan for before you implement CCM? Clinical staff not putting all this burden on your providers. They can help develop those care plans that are then just reviewed and signed off on by the providers. What kind of time tracking system, if it's not directly in your EMR, are you gonna systemically use? What kind of templates and smart phrases for that consent and those other things do you need? Create that electronic comprehensive care plan and then have a month end process where you're billing for all minutes or all time spent by your clinical staff and your providers if you're doing traditional CCM in a one month calendar period. And then you bill for that at the end of the month. And this is just some revenue examples on kind of how much of a difference this can make to your bottom line. Again, this is just if you're considering CCM versus care plan oversight, I would say smaller practices that are just providers that are doing a lot of management of patients that are on home health services, care plan oversight may make a little bit more sense initially as you build towards CCM. And these are the care plan oversight. So I'm not gonna talk about these extensively today, but I wanted you to have the codes and the information for you to refer back to in your resources. Again, the hospice certification code has to be a physician, not a nurse practitioner. These are the easy ones I talked about on that other slide, billing for that 45. When you're the ordering provider for home health services, you can bill for that. So understanding these little extra opportunities for work that you're already doing. I spent a little bit of time talking about remote patient monitoring. And then I know Dr. Seary, you do this in your practice. If you're still on, if you wanna share in the chat a little bit, your perspective on RPM and why you think it's been beneficial for you, I think that might add some color here. But from a coding perspective, as we're starting to use technology to take care of our patients, if you partner with a technology vendor, we can go to the next slide where you have medical devices. So remote blood pressure, remote blood glucose, pulse boxes, things like that, where you have real-time data, physiological data coming into your practice, monitoring that, then you can get paid for the amount of time that you're spending doing that throughout the month. And obviously that leads to helping manage clinical outcomes and things like that as well. Some key definitions to keep in mind. So again, this is kind of what I was describing with the medical devices. It's not just self-reported, self-measured patient data. It does have to be a medical device. RPM does wanna see a care episode. So you don't have to have as comprehensive as a care plan, like you do for CCM, but you should be documenting and measuring specific treatment goals. It shouldn't be something you give to all of your patients. Are you gonna build an RPM program specific for your COPD or hypertension patients or whatever it is? Understand if it's gonna be scaled for CHF. What is your target population where it really makes the most sense to have this real-time clinical data that can help you drive your care plan? So there's lots of different codes. I'm going to kind of take you through how you would bill for it throughout the month. So, when you first set the patient up with RPM and give them that equipment, there's a code for that initial setup and patient education. Because it's a practice expense to actually have the, you know, own the medical device and there's usually a contracting fee with the vendor, you can bill the 99454 once every 30 days for supplying the patient with the technology. Next slide, please. Then, if you're spending 30 minutes and it has to be the provider during that first month, really analyzing all of that initial data, you know, making care plan decisions and treatment decisions and documenting that, there is an opportunity for that. But really, the next slide, this is very similar to CCM, only focused on how we're using technology to drive care plans. Again, these are time-based services. That's why it's important to think about the EHR technology or other service you're going to use to track this. 20 minutes per calendar month, both clinical staff and provider time. If you're doing RPM, some people have more of a specialized role, clinical staff-wise, helping to monitor that, and then each additional 20 minutes. And you can bill up to 60 minutes of RPM time as well. So, again, do your research. There's lots of technology out there. What do you need from a vendor? What's your use case? Don't just try and give these devices to every patient. What kind of care team can help you support this so the provider is not responsible for interpreting all that data, and then really doing patient and caregiver education on the value of this and communicating with it. One example of a program that uses it, so they focus specifically on patients with hypertension or heart failure, or obviously during COVID, post-COVID monitoring. They found that being the most successful for their practice. They had remote scales, remote blood pressure cuffs, pulse oximerators and thermometers. They had a third-party vendor that charged them a flat fee, and they were able, they found that Bluetooth was not working. And they were able, they found that Bluetooth devices or cellular devices versus Bluetooth were much more effective for their patient population. They did have their clinical staff get the initial readings, interpret it, and then fed that back to the provider when anything was abnormal or needed clinical interpretation. So, again, that clinical staff time counts. And these are some of the outcomes. They're pretty early on in evaluating this data, but overall, the providers were satisfied with the technology. They felt like it was a pretty effective use case to help monitor their patients. They expect to slowly see more use of the technology throughout their patient population, and they're thinking about how they can make the use case to seeing the impact in the ER and hospital visits. But this has been especially helpful for their facility patients, they felt like. And, again, this is just a revenue example, kind of trying to tie this all together for you on why we need to think about these things. These are just tools in your toolbox to get you paid for the work you're already doing. Had a lot more interest in remote patient monitoring, given the kind of use of technology that we're seeing now. Annual wellness visits, so these are all just resources that you have. Again, annual wellness visits can be a great time where you're asking your providers to spend more time on diagnosis coding for HCCs or capturing quality metrics, doing those depression screenings, things like that. So understanding what that template needs to look like, there's a resource we've given you for that, as well as if you go to the next slide. All of those remote patient monitoring and telehealth, there's resources for that. I'm sorry, one more slide. These are just highlighting some resources. All of that big slide that said optimize your billing model, this resource called Advanced Coding Opportunities goes over every single one of those and what the requirements are, what the details. Use this to build your cheat sheets and kind of educate your providers on what kind of aligns with your clinical model. I always like to say when you're determining what you're going to bill for and what your billing model is going to look like, think about the care that you're already providing and then what exists to get you paid for that. Again, even if you're on value-based, are there things outside of the care management fee that you could be getting paid for? RPM is a good example of that, because it's generally not included in some of those bundle payments for care management. Any questions on that before I talk a little bit about compliance? If you found things to certain opportunities that you think are beneficial, please feel free to kind of share in the chat and what's been effective for your practice. So, you want to think about a culture of compliance. What kind of standard processes can you put in place to monitor things, to avoid risks, to help your providers, to make sure that you're getting paid for things? The Affordable Care Act made some sort of compliance plan or program mandatory as a condition of participation for providers participating in federal health care programs. But that doesn't mean you have to have a huge compliance department. I want to give you some easy tips on things you can do. So, next slide. These are the seven elements of an effective compliance plan. Why do you want to do this? Again, you can break this down into just bite-sized pieces. Have someone in the practice that's responsible for it. Talk about compliance during staff meetings. How do people report concerns or things that they have? Provide ongoing training and education to your team. How do you respond to something when there is something, you know, going on? Or if you're getting a bunch of denials, are you investigating it and trying to solve that problem besides just not, you know, addressing something that might be going on? If we go one more slide, I want to spend a few more minutes talking about this. Okay. So, when you're doing internal audits or internal monitoring just of your own practice, again, you can start small. Look at five notes per provider. Look at, you know, if you're new to TCM services, just TCM services. Make it a kind of peer-to-peer activity. Do little things that you can kind of just keep a pulse on your documentation and coding habits. Also, looking at billing trend reports. So, whether that's a bell curve report or just a level of service report that shows you the percentage of 99350s versus 99359s, or 49s, excuse me, that your providers are billing. All of your providers are caring for complex patients. So, if there's a drastic change in billing trends from one provider to another, that could just be an education opportunity or something you want to keep an eye on. You want to understand, based on the model of care you're providing, based on the model of care you're providing, what risk areas might be on OIG's active work plan or something that Medicare is looking at. Telehealth services are a big one. Making sure that you're billing, you know, for audio only and remote patient monitoring and video visits versus that appropriately. And then kind of developing your standards from there. You could do a focused review. Again, especially if you're rolling out a new service. How is, you know, CCM going? Are you doing a kind of internal audit for that after you start and looking for education area? And then coding changes annually. Dr. Tang and I mentioned briefly the 2023 changes. So, who in your practice is staying up to date by subscribing to listservs, you know, understanding when the Medicare final fee schedule rules come out, what new coding opportunities are released that may benefit your practice based on the care you're providing. And then especially when you hire and train new providers, make sure that they're getting some standard billing and coding education. You are getting some access to some online courses that are a great continuing education opportunity. But how do you offer that education up front and then on an ongoing basis to your team? So, this is kind of how you could document that you have a compliance plan or you have a compliance program in place just by doing these things on an annual basis. And then also just foster that culture of transparency and collaboration before your providers. Maybe you look at a couple progress notes together during a staff meeting when you're talking about complex patients or you're sharing tips and tricks from one another. Some people do this in a more formal way as part of annual reviews or things like that. But really just, you know, have some opportunity for peer-to-peer auditing or just peer-to-peer sharing and kind of best practices and comparing what your providers are doing. If you foster that culture where constructive feedback is welcomed, that could be a really good thing for you. And these are just specific areas. If you're not really sure what risk areas are for a home-based program, this would be where I would focus my attention. These are the things that I'm looking for in a compliance plan for a home-based practice that you're paying a little bit of attention to. Questions? Coding is complex. A lot of information, a lot of, you know, opportunities that you could integrate. We're just trying to get you paid for what you're doing and do it in an important way where you're not putting yourself at risk. The last thing we want is you to not be on the bad side of an audit because you didn't take that time up front to kind of implement things in an appropriate way. All right. Any questions before we move on? All right. Well, yeah, Brianna pointed you to a lot of different resources. And again, those are in the HCCI Learning Hub, along with all the resources for this workshop. If you have any trouble finding those, please let us know. But why don't we kind of move on? We will have more time for Q&A at the end of today. But at this time, I want to go ahead and invite back Dr. Suri to talk about survival and thriving in those dual environments of fee-for-service and value-based care. So, Dr. Suri? Dr. Suri, are you there? Unmute myself. Ah, I hear you. Okay, great. I don't know why. Last time I tried to unmute myself, I was thrown out of the presentation. So, thank you. Good afternoon, everyone. I hope everyone is still awake. That was really, like Dr. Chang said, a very difficult topic for all clinicians to learn and embrace, but really important, a really important one. So, we'll move on to the fee-for-service versus value-based care, which is, you know, according to me, it has really improved my work-life balance, the value-based system. So, I hope and really, I really hope that all of you will be in a value-based system. And I hope that all of us, all physicians should be in a value-based system because primary care is a lot of work. And, you know, if they are recognizing it, more and more of us should embrace it. I think some of us are just scared of the word value-based, but I'm excited that these are all hospices and, you know, you guys have always done and provided the value. So, I think you will have a harder, easier time embracing this than a lot of my primary care colleagues. So, next slide. So, you know, obviously in the fee-for-service world, you know, there is always positives and negatives, you know, when we talk about fee-for-service. And most of us are very familiar with this. You know, the day we see more patients, it's a positive. We see less patients, it's a negative. You know, if you are driving, if there's a lot of in-shield time and we are driving between patient to patient, obviously it's a negative. If it's a heavy MD staff, then it is obviously a lot of expense. And if you have a lean staffing model, it's obviously a little bit more profitable. Then you are always worried about, you know, if everybody coded to the maximum for the day or, you know, somebody is coding just level 2s because it is easier and they are not worried about being audited. And, you know, everybody believes that if I code level 2 and I keep coding level 2 and I code some level 3s, I'll be fine. You know, then physicians are also afraid because when they have to document level 4 or level 5, even though they might have done the work, it's a lot of documentation they need to do. So they just, you know, people avoid coding higher levels or some physicians tend to code higher if they provided the care. But if they don't have the time to code, it becomes an issue again. You know, the positive is I personally feel being in a value-based system is positive. I can see a change for myself. I can see a change for my clinicians in my practice. That FIFO service was really we were on a, you know, on a wheel and we were just going and churning. And, you know, we needed to churn because like Dr. Chang said, no money, no mission. So and we needed to churn so that we could be in this position to, you know, be able to tell our story. So the, you know, the other pieces, you know, more you obviously need to always have 24-7 access. I don't know of any primary care or palliative practice that is not 24-7 access. So you really need to have, you know, access both whether it is FIFO service, value-based. The only requirement for you to be in value-based is that you need to have not only 24-7 access, but you also need to have an EMR access for the provider who's going to be on call for you. And the purpose of that is that the documentation is obviously the on-call documentation is in the EMR. And the thing is that, you know, if the person is being guided, the person who's taking the call knows what are the medical conditions, what medications they are on, what medications that they're going to be prescribed. There is no interaction and all of those things. So that is a requirement for you to be in a value-based world as the EMR access to the provider on call. Then value-based care, obviously, you really have to have, you know, your ATC documentation because you're getting paid basically for taking care of high-risk patients. And if you have providers in your practice who are going to just go in, see a patient, fall, and there's no, you know, they just gave instability and fall and don't really document what are the reasons for the fall or the causes of the fall. Or like Dr. Chang said, if you have a patient who's oxygen dependent, you really need to make sure that you're coding for chronic respiratory failure with hypoxia, or you are coding for somebody who's, you know, has hypercapnia. And so those kinds of things that need to be put in to be able to tell your story and your complexity of the patients that you're caring for to the providers and payers so that they can give you credit for that. In the value-based world, you know, you do have an opportunity to get paid. And we've always done that. We've always had a document saying that things are not covered, then you guys, you know, that it will be, you will pay out of pocket for those services. And you also do have an opportunity in the value-based world to create other revenue streams like, you know, donations and ancillary and things like that. So and philanthropy, but which really I haven't done as so far, but I think the opportunity definitely exists in the value-based world. So next slide, Melissa. So, you know, I wanted to talk a little bit about both the models, because I think there was a question about what is really value-based care. So I just wanted to make providers aware that, you know, a fee-for-service is what we've been doing. But maybe hospices are not used to that as such, so that you might not be aware of this model. This is a model where I went in, I saw the patient, I told them, you know, you know, I wrote my note and I got billed. I mean, I got paid for what I did. It didn't matter, you know, if I educated them, if they were, let's say, a pre-diabetic and as a primary care physician, I went in, I, you know, I coded pre-diabetes, I might have done a little bit of education, but it was really not, I wasn't really accountable. Like, what have I done? How have I followed up? Have I done chronic care management to make sure that this patient is going to follow through with, you know, all my recommendations of exercise, you know, diet, how to minimize their risk to become a diabetic, how to minimize their risk of other metabolic diseases and everything else. It really, I was never accountable for that. So I was just getting paid for what I did at the moment. And, you know, really, I needed to see more patients to be able to increase my salary. That is essentially what it is. But as you can see, the healthcare policy really thinks that the reason for the inflation is our fee-for-service model. It is, they feel it is a fragmented care, that we are not accountable for what we are doing. We are not worried about the outcomes. We are really not taking preventive care that seriously. We're not preventing our patients with chronic diseases to go on to develop their complications. And that is what our goal should be, that we should really be their advocates, but we should also be their coaches to prevent them from having complications from their chronic diseases to develop into a chronic serious illness. So it is preferred by providers because it's a familiar model. They know, they get up, you know, they have their list of patients that they need to see. They go and see them and they think their work is over. Well, in value-based care, your work does not end. That I can tell you, but yes, you don't have to write as long of notes. And most physicians actually do a lot of the stuff that we do, that they're asking us to do in value-based care. It's just that we never focused on it. We never documented it. We never were paid for it. But now they're giving us an opportunity to get paid for this. Obviously, fee-for-service is really under scrutiny by the policymakers. They think we have over-utilization of services. There is, it contributes to fragmentation and it is overburdening the payers. And the biggest payer, obviously, we all know is the CMS. So CMS feels like they are being overburdened with this fee-for-service and they've been wanting to change this. So the CMS and the MedPAC have had a resolution that they want to move to every practice being part and every patient being a part of an ACO by 2030. So that is where this is all moving. So Melissa, you want to just change the slide? So what is value-based care? So it is care that is dependent, the payment is dependent on the outcomes. So if you have a patient who's a diabetic, if you are able to improve their hemoglobin A1c, if they were at hemoglobin A1c of 13 and now you brought it down to less than nine, excellent. That is what they're looking for. If you have somebody who is a hypertensive and now you've been able to control their blood pressure, that is what they're looking for. There is rewards for improving patient's health. So that is if you're definitely managing a chronic disease, but it's also that you are going to be preemptively and doing a lot of preventive screening so that if there is early diagnosis and early treatment, you will be improving their overall health. You will also be teaching them and coaching them on diseases that they can prevent. If you have somebody who has metabolic syndrome, you want to, you know, if somebody has been diagnosed with PCOS before, you want to be able to make sure that you're teaching them what complications they can have in the future and you're tracking that if they're following all of this. Same way with, you know, reducing the effects and incidence of chronic disease, that you will have a diabetic, you're screening them for their retinopathy, you're screening them for foot ulcers, you're screening them for, you know, cardiovascular disease, you're screening them for peripheral arterial disease, so, and so on and so forth. So you're really trying to detect all these things early and really change their trajectory. Helping them live healthier lives, and all of this care should be evidence-based. So what they're trying to say is that, you know, just, I think most of us in primary care have dealt with, you know, low back pain, you know, that is the most common morbidity. The most common complaint in a primary care setting is low back pain. So when somebody comes with low back pain, your ultimate knee jerk should not be a problem. Knee jerk should not be, let's get an MRI. You know, what is evidence-based? Evidence-based is, you know, exercise, lifestyle, weight loss, you know, physical therapy. And then if there is no improvement, then you go on to an MRI. And, you know, what is the purpose of getting an MRI? Are you thinking of, you know, any intervention? Are you thinking of, you know, an injection or you are thinking of surgery? Only then would you want to get an MRI. Unless and until you have other reasons, which you, you know, then you have other reasons means that you are thinking of a malignancy or something else that is you need to have other reasons that you have built a case for. So everything that you do should have evidence-based. So what is the value coming from? The value is basically they are trying to determine what is the outcome and how much it costs to get to that outcome. That is where the value is coming. So you know, there are many studies that have been done and they are saying that the value-based care, the value in care is not necessarily expensive care and there is care that can be provided at lower cost and still have better outcomes. And that is what they are looking for. So Melissa, next slide. So there is an article in the New England Journal of Medicine, which was posted by the Massachusetts Medical Society and the benefits of value-based care for patients, obviously, who are the real people that we really care for is, you know, it obviously lowers costs for them because they also have a part of that co-payment that they have to do for all the services that they undergo. So if it lowers costs for them and improves their outcomes, what better can it be for the patients themselves? Providers, I'm a prime example, higher patient satisfaction rates and better efficiency, definitely can attest to the better efficiency. And I think, you know, our satisfaction rates have been consistently high. So, and I, you know, really significantly say that it is because of my team that we've been able to get together. The payers, you know, they have better cost control and they have reduced risk. What more are they going to ask for suppliers? You know, they know what is going to be consistency with, they're not going and looking for, you know, oh, I did not get a prior authorization on this. And I will not get paid for the DME that I gave out because there is no documentation. And, you know, there is alignment of prices along with the patient outcomes. So they are happy. Society, obviously overall, because there is reduced healthcare spending and better overall health. So this is what we are all looking and striving for in value-based care. So next slide, Melissa. I know that Brianna presented this a little bit, and I will have another slide on this again later on in this presentation, but really what CMS is looking for in your value-based practice is access. Access means not only access between 9 and 5, access 24-7. They are looking that you will have a 24-7, you know, triage phone call, whatever you might say, answering service. Whoever is going to be the provider is going to be on call. They are going to have an EMR that is ONC certified. So I think the latest version, I think it's 2015 ONC certified EMR, and that there is going to be continuity. You cannot have, you know, the patients of your practice being covered by somebody else who does not know anything about you. And the continuity, they also look at, you know, I have been doing this for the last seven years now, so I can tell you they are also looking for, like, if it's my patient and I'm their primary care provider, that consistently I should be able to see them even if it's an emergency. If it's a same-day visit, I should be able to see them rather than this patient being shipped to another provider in my practice. There are obviously circumstances where I'm on a vacation or something like that. They give you that leave, but the 80% of the visits in that year should be provided by the primary provider. That's what they're looking for because, you know, otherwise, without that continuity, they feel that the care is still fragmented. Again, Brianna talked a lot about care management. So care management is a big part of value-based practices. That is what you get paid. That is the money you get paid quarterly. And that is that you have to have a system that is going to be able to provide that for your patients. They need to be able to access that team. And what we have done in our practice is we've created teams. So there is a physician, a nurse practitioner, a medical assistant, an RN, the social worker, and the psych APM that is assigned to that building. We've divided by buildings because it makes it easier because we know which providers are going. And so let's say a call is coming in and, you know, it's about DME. So we initially routed to our, you know, so our triage knows our medical assistant, but routed to our social worker. So we know that, you know, what is the need, who recommended it. And so we've collected all that data. The information goes to the nurse practitioner. So it's pretty coordinated. And then we obviously have the IDT that we discuss it in. If the nurse practitioner has an, you know, you know, why, why not? She can call me. We always also have the needs to be documented in the EMR. So there's a lot of things that go into providing, you know, the complex DMEs. And I'm not talking about a walker. I'm talking about things like electric beds and, you know, wheelchairs and jerry chairs that need to have real documentation EMRs. So there's a lot of care management that goes in. But if you have team, there is continuity and there is a lot of satisfaction as far as, you know, the patients and the families. And because at the end of the day, your value-based payments do depend on your patient satisfaction survey as well. So comprehensiveness and coordination. So comprehensiveness, you know, they are, there was a time when Medicare used to say that everything that you needed done needed to be done outside the doctor's office. But now they're looking for more and more stuff that you can incorporate into the primary care practice. So that's why we've really integrated behavioral health into our practice because we had a huge need. We have a lot of patients with dementia. So we got the psych APN and our LCSW into our practice. We also, you know, do obviously a lot of palliative and hospice, you know, and do all of those things into our practice. We've also developed care packs with cardiologists. We do have a cardiologist that does home care visits for us. It's very rare, but we are lucky enough to be able to get him to do that. And so a lot of coordination between the consultants and the primary care practice, which is a big requirement. They're in fact said that you need to have care packs with the provider, with their consultant, with your consultants, that they will see patients at an emergent and urgent basis if they're recommended by you. So that even that language is included in those care packs. Patient and caregiver engagement is we have, obviously we do a lot of patient family advisory council meetings, which are, which were initially a requirement of the CPC. So that's how we developed it. It was requirement quarterly. It is not a requirement of the primary care first, but it is the patient and caregiver engagement is extremely important because a lot of things that we, a lot of things that you will need to make changes for in your practice, you know, things like team-based care, things like group visits, or we have our support groups that we arrange for our practice by my psych APN and LCSW. A lot of those things, you really need, you know, patient champions in your practice who are going to be willing to do this. So we had from our PFAC actually came out a bulletin, a monthly bulletin that was devised by one of our patients and, you know, they highlighted, so he does it monthly now and he puts out all the things that we are doing, you know, the talks that my LCSW is doing, or the talk that I'm doing during COVID. We, it was a great thing because we were doing talks almost every week, you know, educating our patients on what to do with COVID when it initially came out and what not to do. And, you know, we talked about a lot about masking and social distancing and vaccines eventually. And, you know, I have to say that because of the talks that I did with the patients and my staff was on those calls, my staff acceptance of the vaccine was a hundred percent. So, you know, I think that was probably the most, the best outcome that we could have had. Then we have, you know, obviously they're looking for planned care. So planned care is really essentially what they're looking for is that you are really, you know, any, any chronic disease that this patient has that you are planning what they're, you know, so care plan, the care plan that, you know, Brianna pointed out, you know, who the care team is, what medications they are taking, what is changing, why are they changing? You know, if you are really coordinating their care about their consultants and then population health, you're looking at your practice from, you know, a higher point and seeing that, you know, how are my diabetics doing? Are they improving? Are they, you know, taking care of their consulting? Are they, they're seeing their consultants as needed? Are they getting their colonoscopies done? Are they getting their flu vaccines and pneumonia vaccines done? So looking really from up above and looking at your practice as a whole, that is what they're looking for you to do. So again, I will stress that if you guys are starting out, look for an EMR that is, you know, is capable of doing all of this. Doing it by hand is extremely, extremely tough. So next slide, Melissa. So this is a little, this slide I just wanted to put in because the success of your practices will really depend on how easily and are you able to adapt to change? Because when you start with a value-based model, there are so many things that are going to be thrown at you when you go into a, let's say you start with primary care first, or you start with independence at home. There are going to be so many requirements that are going to be thrown at you by CMS. And even they understand that you cannot change everything in one day. So don't get overwhelmed by looking at all those requirements. So that slide that I just showed you the right before this, I can tell you when I looked at that slide and I had signed up and there was no other practice in the area that had signed up for the CPCI, I was like, oh my God, what did I get myself into? And then I kept thinking, nevermind, I'm going to just sign off at the end of the year. You have an opportunity, I have the chance to just sign off and I might sign off. But I can tell you that, you know, we were lucky in CPCI and CPC, there was a lot of coaching. So we had coaching from CMS on how to change primary care first. We do not have a lot of that coaching, but they do know that there is going to be a time where you're going to be ramping up and they expect that time for you to be ramping up. And that's how they have, you know, developed their quality scores and how, what is your utilization going to be? A lot of us might not even know what our utilization is. I mean, I didn't know before I started in the value-based system that what my utilization was. And, you know, when I started out, I'll tell you, I looked at my home care utilization and I had my patients on home care that were getting monthly B12 injections. Okay. And I was like, hmm, and my nurse practitioners were going in also to see these patients. So I'm like, why do we need two services? So, you know, we, so that is what we had to actually, you know, that is how little of a detail we needed to go into and what we were utilizing services for. And there was nothing else going on with those patients except for getting a B12 injection, whereas my nurse practitioner also was going. So there was a home care agency going and seeing this patient once a month and then my NP. So we needed to, you know, scale back on our home care that way. And so really looking at yourself and your practice and then be willing to change. That is the most important thing that I think is in value-based care because every day is going to be a new challenge. So we've all worked with MACRA before, and now we all know that we are in QPP. You know, all our quality scores have to be going through that QRDA report that we have to send that has to come out of your system. It cannot be hand done anymore. You know, there was a time where we used to submit PQRS where we used to select 20 patients and then we used to submit their quality data to CMS. You don't have that opportunity anymore. You have to, all of the data about all of your practice has to go directly from your system. So it is extremely important to select an EMR system that is going to work with you and that is going to work with you and make the necessary changes so that you might be required because you can choose whatever quality scores you choose to submit, at least initially, unless you get into one of these value-based programs where then they're going to assign you scores that they're looking at. So look at the systems and their willingness, the EMR systems and their willingness to change as well. I personally, when I switched to value-based care, looked at it as an opportunity and it's a very small, you know, drop in the ocean, but I looked at it as an opportunity to transform our healthcare system and, you know, really be able to have that dialogue with the payers. And this is what I love to do. I actually love to have that dialogue with the payers. I really go in front of them. I bug them all the time. And, you know, so I talk to them like, what is it that we can do that will make you understand what we are providing, the care we are providing, the value we are providing? So this is misspelled a little bit, this slide, but this next slide, but what I meant to say is that I think most of you are already doing most of this stuff that they're asking you to do. Most of you are on call 24-7. You might not realize it, but you might have cloud access to your EMR anyways, and maybe all of your providers have cloud access to your EMR. You could access your EMR from your home and you're all doing the quality reporting anyways. And I think that it is, I just want to tell you all that I think you should all strive to go into the value-based model. Next slide, Melissa. Sure. And Dr. Suri, there was a question in the chat. Somebody wanted to know what EMR you're using. So this is not a, this is not a, I'm not doing any of that, but I can tell you that the EMR that I'm using is probably one of the smallest companies. It does not have the bells and whistles, but I have transformed that EMR from using, you know, they, they are very, very simple. Glenwood Systems, it's probably one of a very small company, but we've transformed it since we were part of CPCI to CPC and now to primary care first. You know, we've had care plans built in. Brianna has seen a lot of it. Maybe Brianna has access to other EMRs so she can tell you also. I love my EMR because, you know, they, first of all, they're very responsive. That's the reason I love them because, you know, if I tell them I need this template built in, two days later, I have the template built in. So, and all the quality metrics, all were built in by us, as requested by us. They were all built in. I get a quarterly report on, you know, that I'm falling behind on these metrics, like, you know, the colonoscopy screenings are, your score is only 39%. You know, so then we know that I need to get my, I have an RN student who does my quality stuff for me in the office. So I'll tell her, you know what, these people are eligible for colonoscopies or Cologuards or whatever. She starts making the calls. So I'm able to generate those reports and then follow up, you know, schedule follow up things with our patients. So it's pretty simple, but it is, you know, I'm not marketing for them, but I can tell you that they're very open to adapting to change. And that is what I was, I keep saying again and again, that you know, you're going to come up with new things. So if your EMR vendor is willing to change, it's not a significantly added expense. I think that's what you're looking for as an EMR vendor, for in an EMR vendor. And you might have somebody that is willing to change for you and, you know, adapt as needed. So now we have care plans built in. We had our cognitive screening built in. We have our advanced care planning template built in. We have our annual wellness visits template built in. So not only my NPs and physicians know, but also my MAs know, you know, which template to open at what visit. And, you know, so it becomes easier and they've done half the work for us even before a physician gets into the room. So, you know, they know that the advanced care plan, like the five issues needs to be in the room or the pulse needs to be in the room or, you know, so nobody's running around with stuff in between the visits. So it saves a lot of time for us. Thank you. Absolutely. So we'll go into the next topic. So Medicare, you know, there are two branches of the Medicare that can make and bring out new projects. So new programs, one is the legislative branch and the other one is the CMMI. And we all know that CMMI is, has been the one that has been bringing out a lot of these projects into the value-based projects as into the market. And their goal is really to have every beneficiary, every Medicare beneficiary under an ACO by 2030. That's what their goal is. This is their overarching goal. Now they've had two ways to get to this. So they came out with their ACO model and believe it or not only in 2012. So it's not that long ago. So they came out with their first ACO model in 2012. And since 2012, now we have 500 ACOs with over, you know, I think one third of Medicare beneficiaries are in ACOs now. And so they have two thirds more to go by 2030. And what they have done is when they came out with the initial ACO models, most of these models did not have a risk attached to them. So they were only, they were only going to take the benefit of the upside, but they had no downside to them. But as, as, as they progressed, they also realized that by 20, in 2019, they created a, what is called the pathway to success. And they wanted all of these ACOs that were in the initial models to take on more risk. And as they didn't want to leave them with no risk at all. So all of these ACOs that initially started, they all have to go on to take risk. Then Medicare came out with another model, which is called the direct contracting model. And in the direct contracting model, which was basically like an ACO, but what they were, their, their whole aim was that they wanted to give the providers more leeway in designing these models. What ended up happening was that there was a lot of other players that got into the direct contracting model who had no experience with healthcare and who had never done healthcare before they started getting into the DC model. And then they evolved that into the ACO reach model. And that ACO reach model is what came out of the DC. And we all know that in the ACO reach, they are, what, what are they are looking for is that they are going to have a, you know, in the first basic ACO reach, they're going to have a 50% upside and a 50% downside means let's say they save, ACO reach saves them money. Medicare is going to keep 50% and they are going to keep 50%, but if they lose money, the ACO reach is going to have to pay 50% also. And then as the enhanced ACO reach is going to be there where, you know, as, as these basic ACO reaches go on to the enhanced model, they are expecting it to be a hundred percent risk. So there, so really it's a tougher version of the ACOs and it is, you know, it is only because what happened when the DC models came out, there was a lot of players that were not, according to Medicare, the right players. So next slide, Melissa. So again, I'm sorry. I talked about the ACO REACH model, but we all know the Medicare Advantage Plan, which is called Part C Medicare, which is essentially your Clovers and United and Optum and Aetna and all of these that have Medicare beneficiaries, and they are responsible for their Part A, B, and some of them for Part D, and some of them will take a different Part D plan also. So that is what is their Medicare Advantage Plan. They have the Primary Care First, which is another model that came out of CMMI, which is what I just described. For that model, you have to have, again, an EMR that is ONC certified. You have to have 125 beneficiaries that are under straight Medicare, and all the other elements that I described earlier on that slide about access, continuity, care coordination, plan, and population health, and basically a lot of coordination with the providers and their consultants. So this is what their models are as of today. Next slide, Melissa. So this is a lot of what I just told you about what their, the ACO reach, what are they expecting, and what are their goals. So there's a lot of detail in that. You can just go through it. If you have questions, please reach out to me. I'm more than happy to answer, but this is just a lot of detail about ACO reach, because I know, I think one of our practices is an ACO reach that is in the audience today. So next slide. Again, I just went over this, the standard ACO, the new entrance, and the high-needs population. So it's different levels of ACOs, which will have different risks with the CMS, and essentially, no ACO is going to be without risk going forward. They've actually taken away the basic ACOs. The basic MSSB model has been scrapped. So if you were in it and you need time to get on to the next model, you're there, but there are no new ACOs that are coming out, but just the basic ACOs. This is basically, essentially, you're responsible for your population. Obviously, you'll have to pay a lot of attention to the social determinants of health, because you're going to be totally responsible. So you're at full risk with Medicare. So you'll have to be attending to a lot of care, the social determinants of health to be able to improve your outcomes. And obviously, in this one, they have talked about the expanded the nurse practitioner scope of practice in this model, because a lot of these models are in the rural areas as well. So again, it's all measures that will be claims-based. That's how CMS reviews, right? Whether you did advanced care planning, if you're coded for it, only then they're going to count it. It doesn't mean that it is in your notes. It doesn't count unless you've coded for it. They are, so even for the ACO reach and in primary care first, in the category that I'm in, it's days at home. They're really looking at days at home. So whether if the patient was in a skilled, patient was in a hospital, they're all considered negative for us. We really need to be able to manage patients at the right place and in their home setting. And that's what CMS is looking for, really reducing the cost, especially if it is related to their chronic condition, that is considered a big negative. If it's any, you know, there are conditions where you need the hospital, like, you know, there is sepsis. Now we have Brianna here, who's doing medically, you know, hospital at home now. So it is, you know, they are also looking at those models. There is a model that is in New Jersey also that has started. So I'm going to be talking with them to partner with them myself for our practice so that we can succeed in our value-based care because days at home is a big model. It's a big measure for our practice as well. And it is days. So whether they were in the ER, they were in subacute, whether they were in hospital, all days are considered negative. And of course the big piece of every value-based is the CAHPS survey. Your satisfaction, patient satisfaction survey is extremely important. So you cannot have a low satisfaction score even if your quality is high and your utilization is low and your satisfaction is low, that's a big negative. So next slide, Melissa. Again, I know Brianna included this slide and I've also talked about all these elements so we can switch to the next slide, Melissa. I think I also talked about the PCF requirements. Obviously all primary care practitioners, 125 Medicare beneficiaries. Obviously we have to be providing the primary care. We have to have had experience with value-based ONC certified EHR. Also, you have to have access to a health information system because they are looking for interoperability. That's a big piece for them. And a test to 24-7 access and advanced, yeah. So this is, again, they've assigned you risk categories according to your ATC scoring. So let's say our practice is in group three, so we are getting $100 per month per patient. That's the bundled payment. And so we get only $40.82 per face-to-face encounter. So whether I do an annual wellness visit or I do a TCM visit, or I do a follow-up visit, or I do an acute care visit, every visit is $40.82. So there is no other payment except for we have a payment at the end for if we meet our quality metrics, if we have decreased utilization, if our satisfaction scores are high. So then there is an upwards of this that you can get. Next slide. So this is how, this is a lot of detail into this, but I can tell you that, again, you have the professional population-based payment plus your flat visit fee, and you have an opportunity to increase your revenue by 50% if you are meeting all the performance-based measures. So that's all we all need to know. But if anybody wants to go into a lot of these details, I'll tell you. What happens is that when you're looking at your quality metrics, they have two benchmarks. So if you meet the 50% quality benchmark, then only will they look at your utilization. But if you have not even met the 50% benchmark for your quality, they're not even gonna look at your utilization. So there is no chance of you going into the performance-based money. So then you have to meet the 80% benchmark for your quality to be able to be eligible for looking at your utilization and then getting the enhanced payment. So there are two tiers, even in the performance-based adjustments, where you meet 50%, then they look at your other metrics, and then they can give you credit for the other metrics. But if you have not met your quality gateway, you are not going to get other metrics looked at. Next slide. So in the PCF model, so like I said, we are our practices in group three and four. So what they are looking for us is the CAHPS survey. Our advanced care plan and our number of days at home, but for the risk categories one and two, they're looking again at the CAHPS survey, but they're also looking at the diabetes control, high blood pressure control, colorectal screening and advanced care plan. And I'll tell you why they are doing this. So everybody thinks, oh, you're in group three, it should be okay, it should be easy. But I can tell you that number of days at home is a very complicated metric. And CMS itself was having a little difficult time explaining this to us when we did the initial calls. And you cannot have a lower days at home metric if your diabetes control is poor, or your blood pressure control is poor, and people are going to the emergency room because their blood pressure was 200 over 100, or they had a hemoglobin A1C of 10, and they're having UTIs and things like that and landing up in the emergency room or ketoacidosis. So you need, what they are assuming is that in risk category three and four, you're already meeting all these metrics. And that is why you are in risk category three and four, because that's why you've done a better ACC coding. You are obviously identifying the problems, you're coding for them, and then hopefully you're responding when you're coding for them, and you're taking care of those things. That is why you are in risk higher categories. And so you're probably taking care of all of these, so they're just going to do an overall days at home for us. And then every ER utilization, especially for something like a URI, or a blood pressure, or diabetes is considered extremely negative for our groups three and four. So next slide, Melissa. These are some of the definitions that, obviously we've used a lot of abbreviations, so if you have questions about that, these are some of the definitions that you can slide, go through. And again, I'm really open to questions even at the end, or if somebody wants to email me, I'm happy to do that. So this is the basic ACO model, the MMSP. That is what was the first ACO model that came out. And it is, you are accountable for the entire patient population that you're going to be serving. You had to have 5,000 patients. You're going to be coordinating their care, whether it is transportation, food, medications, all of those services that you're going to be coordinating. If they need home care, or they need hospice, whatever it is, they're going to be coordinated under the ACO. Investment in high quality and efficient services. Obviously, as an ACO, they will be looking at, who am I partnering with? So when I partner with a cardiology practice, right now I'm partnering with them because I know that they will have, I have easy accessibility to them. I can call them at any time and they will see my patients urgently, and I can easily reach them. But when the ACO is getting the information from CMS, they're also getting information about, this provider is a high quality provider, but is a low cost provider. Whereas this cardiology practice is a high quality provider, but their cost of delivering care is extremely high as well. So that's what ACOs are supposed to look at. They look at every service from that angle that you are high quality and low cost. So, and that is what is called efficient services management. And ACO has to really do that. And when you partner with an ACO, they will tell you, this particular home care agency is high quality, but their cost is extremely high. Or this agency is extremely high quality, but their cost of providing the same care is pretty low. So maybe you need to partner with them. And then again, this hospice agency has, you know, this is their return to hospital, return to hospital or ER utilization, versus this hospice has this return to emergency room. So they will go through each and everything with you because they get all of this data from CMS and they are accountable for that. So they will educate the practices. Obviously now they are all required to assume risk for populations and offer alternate payment methodology. So what it means is that if your practices is partnering with an ACO, they should be able to share the savings that they've had with the CMS. They should be able to save and pass on those savings for the work that you have done to you. So that is what is meant by alternate payment methodology. That means that you should be able to get money for the services that you have provided, the care that you have provided, if you have been able to reduce the expense for the CMS. So you should be able to get paid from the ACO. And, you know, the reason that they put that line in is because if you remember from Stark, you know, you could not be getting monies for the care that you provided. You know, you got paid, you got paid, but you shouldn't be getting other payments. But this is what they mean by alternate payment methodology from the ACO. So next slide. So the Medicare Advantage plans, we all know is what is called a Part C. So you usually have the Part A, B, and D clubs together. You could also have some Medicare Advantage plans have A and B, and then other people buy the Medicare D from another organization. You can do that. So they are all responsible for the entire population. They get assigned a certain amount of money for a certain patient population. Again, they also get allotted money according to the HCC scores. So that is why they're also looking to partner with you as a primary care provider or a palliative care provider to make sure that your HCC coding is appropriate so they can get the access from CMS to those monies. And they are obviously measured by CMS as well. So they are measured by the effectiveness of care. They are also measured for their access. You cannot have a Medicare Advantage plan would have only five providers in the area. And then the patient does not have access to the providers in the area. So they have to be selective, but they also cannot be that selective that there is no access to care for the patients they serve in the region. So they also have to have a patient care survey. They also go through that. So experience of care is definitely number one for them as well. Utilization, obviously, as well. And that's why they come back to the primary care provider or the palliative care provider asking them that, why this? And you know that there is a lot of news around this. They have a lot of more prior authorization compared to simple Medicare patients. And that is the reason because they're always looking at the utilization. I have a lot of positive experiences with prior auth as a primary care and a palliative care provider. So we all have stories about that. And they should have the ability to contract with providers and services to meet their population needs. So this, just because you're a Medicare provider doesn't make you an automatic Medicare Advantage provider. So like I mentioned in the previous slide and the previous presentation, make sure that you're credentialed with the Medicare Advantage plan for whatever services you choose to provide. So next slide. So there is a lot of special needs plans that also, that CMS came out with. There is, you know, I don't know if, but in obviously in geriatrics in our community, ISNPs are very common. Optum is one of those biggest ones. It used to be Evercare. It is a United product. It is, you know, for patients who are in the skilled nursing facilities. So it's an ISNP, but there are, there is a PACE program, which is for dual eligibles. That is also a kind of a special needs program. There is the, there are also chronic kidney disease and ES and stage renal disease programs. There is now dementia programs that are being developed. So, you know, dementia was never part of the HCC coding in the past, but so now they have recognized that dementia patients obviously have high utilization. So now they're coming up with the skilled nursing with the special needs programs for dementia as well. They work similarly to the Medicaid Advantage Plan, but they're built specially for those populations. So like I said, you know, the ISNPs are for skilled nursing. The PACE programs are for Medicare and Medicaid. And then, you know, different diagnosis, they build different programs. Next slide. Okay. So contracting with the pairs, this is a very, very interesting topic for me. And I'm really very passionate about this because I will go and fight with them. And so, you know, but to, for us to go and talk to them, we need to have things that in our own system that we are able to tell them. So, you know, the most important part of this is your HCC coding. And for any provider to be able to make a pair understand what is the population that you're caring for and what is their benefit in partnering with you, you know, they can only understand that because they understand this language. There is no way for them to say, I understand this language. There is no way for me to go and have a talk with them and just say that, you know, I'm a geriatrician, I know palliative care, I can provide this. Well, no, I don't know. They don't know this language. They only know, you know, do you have your HCC codes? Do you have your risk score? And what is your utilization being based on your claims? For the last two or three years, what was your ER utilization? What was your hospitalizations? What is, how much SNF did you utilize as a practice? How much of home care are you utilizing? What is your preventive scores? How are you doing chronic care management? What is your process for, you know, triaging acute care services and need for acute care services? So what is, how do the patients have access to you? What is your patient satisfaction scores? So all of these things, I know I've talked about this over and over and over again, but this is what they look at. This is what, when I go and talk to them, this is what I have to have. This is the bare minimum I need to have. And then they will obviously, you know, and all of you know that, that, you know, they have you as a premium provider, as a tier one provider, as a tier two provider. And it means a lot for the patients because if you're a premium provider and if you're a tier one provider, you know, with a pair, your patient's out-of-pocket costs goes down. So, you know, right now, a lot of providers are not understanding this, but as this builds on, you are going to get affected. If you have a tier one and a premium provider next to you in your area and patients go and have to pay almost no co-pay to go and see that provider, where do you think they're going? So they might not recognize it in the six months or the year that it happens, but they will eventually recognize it. So I think, you know, keeping a tab on all of these things, if you are really planning to get into value-based care, which you might not have a choice going forward, you know, for the last 10 years, we've had a choice, but going forward in the next five years, I don't think we will have a choice. I mean, the way this ACO has taken over from 2012 to now 2022, in the last 10 years, the way they have gone from just being a basic thing to now actually having significant risks, you know, this is moving much faster than we all anticipated because we all think, you know, CMS, it might be slow, but it has really been fast and they're really moving with this. They're really moving with this. So you really need to be able to focus. And you know what? If you think that your practice is great at managing CHF, then go and present just on CHF, don't talk about COPD and dementia. You know, if you think your practice is great at talking about dementia and the care that you provide to the patient and the caregiver and the support services, then talk about that. Don't talk about CHF and COPD. And believe me that payers are ready to listen at this time because they really need to reduce their costs. And in addition, the cost of CMS. So even Medicare Advantage plans have to report back to the CMS. So they are also looking for partners that are willing to partner with them to reduce the costs and utilization. So next slide. Okay. I think I've talked about this over and over and over again, but you know, the success, your success in this program really depends on what you identify is your strong point. Obviously, you need to know what the demographics of your population that you serve is, what are the gaps in care, the gaps in the quality of your care. You need to be able to feel responsible for the cost of care that you provide to this patient. You have to be willing to look at data and financials readily. I mean, I said this earlier to Brianna, I have never done budgeting, even though I was a practice provider and have a small business, I've never done budgeting in my life, but with Primary Care First, extremely important. I mean, it is getting much more important to really be able to budget and really put the resources where they are needed the most. We all would love to provide everything that we have to offer to all our patients, but it is, first of all, not their need. It might not be their need. And also, it is extremely high cost to provide everything that is available or everything that you have to every patient that you have under your umbrella. So it is extremely important to focus on your high risk, high needs population, and then focus your resources around there. And then eventually, continue to trickle down some of those things that you've learned through those into the entire practice. So this lesson I learned very late as I was going through CPC is because I personally, when I'm seeing a patient, never bothered to see, are they a Medicare patient or are they a Medicare Advantage patient or they are a commercial patient, or never thought of this. And most physicians and clinicians do not. But unfortunately, as you are moving into the value-based, you are going to need to look at it because you are being measured. And if your resources are running thin because I have one licensed clinical social worker, I cannot have 500 patients that are seen by her. So obviously, I need to prioritize who needs to be seen and what is the low-lying thing that we can all deal with as clinicians, or my care manager can deal with it, or my medical assistant can deal with it. So I think that is what you really need to do is to look at your budget and look at your patient population, assign the resources that are needed for those patients. And obviously, to be really successful in the value-based models, you need to really have good HCC scoring. You really need to be able to tell the story from your ICD-10s to the payers that what is this patient? This patient has dementia, dependent on a wheelchair, requiring being fed, has dysphagia, has aphasia, the needs need to be met, assessed and met and anticipated. So all of those things that you need to have in your HCC coding to tell the payers how complicated your patient is. And obviously, it's a negotiation. It's never going to be, and as you're starting out, you might be on the lower level, and it is okay, but getting your foot in the door is extremely important. I'm losing it already. But it's extremely important because those conversations are never, it's never a one-time, it's an ongoing conversation. So I'll tell you, I negotiated with a payer in, not in New Jersey, in another state, on the palliative care model. And initially, when we paired with them, they needed us to do a monthly call where I was doing the call with the payer, and a weekly call between my IDT team and their care manager at the Medicare Advantage plan. So every DME that we thought of, or every physical therapy that we thought of was important for this patient that really needed to be scrutinized and so we said, okay, we'll do it. It's gonna obviously take away time from our caring for our patients, but we needed to build that. And so we did it. And now we are on, they are completely comfortable with us. We only do this once in six months. So we needed to prove ourselves. Initially, we were also reporting on, once they sent us a referral, how soon we contacted the patient, how soon we saw the patient, and all of those details we had to go through, like the phone outreach was done within 48 hours, we saw the patient within seven days, which discipline saw the patient, when did the social worker see the patient, when did the chaplain see the patient. So it was, we had to report on all of these things. And now we are not reporting on all of these things because they've already seen how much savings we have brought on for them. We've reduced their ER utilization by 73% in the first year. So that model in itself, and now they're like so comfortable. We obviously report every six months, we report on our essential KPIs, whether we have an advanced care plan, there is a surrogate in the chart, there is things that we also report, obviously we report ER and hospitalization, we track it ourselves, but they also track it on the other end. And we obviously noticed a higher spend in the pharmacy because we were obviously making sure that our patients were compliant with their medications. This pharmacy spend went up, the physician utilization went up because obviously we were one of the physician utilize, we were one of the services that we were providing care, but we also made sure that the patients were following up with their consultants as needed. And we also had a lot of psychiatric consultations that we put in place. So, but their ER utilization went down dramatically. And so it was a real successful model. So, like I said, it is a negotiation and as you are working with that pair, they will get comfortable with you and you will get comfortable with them and you will learn in the process. And so it is, like I said, it's an ongoing conversation. It's not just that you stop at one and done. Next slide, Melissa. Are we running late? That's why you came. We are, and I was actually gonna suggest if, because I think you've mentioned that you've probably covered a lot of the things on these next several slides. We wanna just, you know, kind of go through that. Like, just- I think this is all I've spoken to already. I've spoken to this. So you can go on to the next slide. Again, I've spoken to this as well. So your own scorecard, you need to take your own scorecard and they're gonna come back to ask more, but you need to have at least some of this. And again, this is all what we've talked about already. Yeah, so everybody will get copies of these slides. So it's good resource material. Yeah, you can, it's, I think we've talked about all of this. Yeah. And then the types of value contracts, I think we've talked about a lot of this. Yes, we've talked about a lot about all of this. Yeah, so this is exactly what we've talked about. Decide your clinical model, you know, and then look for your partners and go and deliver to the payers, negotiate with them. Yeah, thank you. So any questions for Dr. Suri? I know there's a lot of questions in the chat, but I will tell you that, I'm sorry, I have not read any of those questions, but I will go through them now. Yeah, you know what? Yeah, a lot of people are, and this is wonderful. I love seeing the exchange of information and experience among our learners with different EMRs, you know, pros and cons and things. I think that's kind of the big takeaway there. But what we're gonna do now is I wanna go to break and then we are gonna come back. We're gonna start a few minutes before 3.30 central time because I wanna make sure we have enough time for our last two sessions on strategies for success and then self-care and avoiding burnout. So let's plan to come back. I'll say this is really precise, 3.27, just because I wanna make sure we get started right away, no later than 3.30. So we'll take a break and see you back here in about 10 minutes. Oh, and thank you to Sarah for always remembering about the recording. If that was up to me, we would forget it every time. So thank you all so much. We're gonna dive in and get started with strategies for success, diving into the details. So Brianna, take it away. All right, thanks, Melissa. So thank you all for hanging in there in this virtual. We really wanna hear from you. So encourage chat communication and kind of sharing as we're going. We talked about kind of planning for your business model earlier today. And now we're gonna talk about some of the more tactical considerations that come up when you're operating a practice. The next slide. So we've kind of laid out five strategies or important considerations. And we're gonna talk about what productivity and staffing and some processes that are gonna impact your bottom line and then build a little bit more on how you demonstrate that story and that value and identify those right partners. Next slide, please. You can go one more. This is kind of just outlaying the objectives. All right, so let's start with productivity. The thing we don't like to talk about, right? And so when I'm saying setting productivity standards, I'm not encouraging unrealistic visit expectations. You know, this is gonna be a lot different if you're setting productivity standards for fee-for-service versus value-based. So, you know, I'm gonna start with a scheduling guide. Your scheduling team needs to understand what a full schedule typically looks like. And so they can help rearrange patients and make the most of provider's time going into the home, make sure patients that are seen in the same area are scheduled appropriately. Gone are the days, or almost gone, hopefully, of RVUs and just visit standards and things like that. We wanna think more about what do we have to do to be able to have a full schedule of patients that we're caring for and to be able to operate a financially successful practice. How many visits should you reasonably, without sacrificing quality, be able to do within a day? That's also gonna change if you're in a very rural area. And your scheduling staff should be able to have some guidance on the different types of visits. So sometimes people assign like units or create, we're gonna talk tomorrow about a scheduling guide, more time with new patients or for a transitional care follow-up than they do for established patients. So how do you think about the visit type when you're determining those productivity standards? And without sacrificing quality, kind of have that clarity on what needs to be done. But you do need to have a standard or kind of a number in mind on how many visits realistically need to occur. Again, for you to care for the caseload of patients that you've committed to, you need to be able to keep a financially stable practice. So variables that impact the bottom line. If you have really low productivity, and this is kind of why we start with that, so less than four to six visits a day, that's gonna, especially in fee-for-service, really kill you from a revenue standpoint. We know that we can't see as many patients in an office as we can in the home because we're driving, they're more complex, they need more time. That's why facilities and clustering patients in the same geographic area or having less drive time is gonna help with that. You also need to consider your staffing model. So physicians versus nurse practitioner ratio or physician assistant ratio to physicians. What are your billing and coding habits look like that we talked about? And are you managing denials? And are you seeking those value-based payment opportunities that Dr. Siri spoke about? Or even just contracting directly with Medicare Advantage. They've never been more eager to listen to home-based practices than they are now. But you have to be able to deliver on all of those comprehensive primary care functions that we talked about. Those patients and their caregivers need access and response time, and you need to be doing all of those things and tracking and reporting those things in a succinct and systemic manner that demonstrates your value. But really understanding, I would say, especially for hospice organizations that are going to provide this, Dr. Siri talked about not using all of your resources at once, right? You feel like hospice providers, you have chaplains, you have social workers, you have all these breadth of services, really understanding what's the difference for home-based primary care and how do you use your resources in the most strategic way. And then look for other kind of revenue streams, steady incomes, medical directorships, maybe taking on a couple of nursing homes, maybe exploring contracts specific for annual wellness visits, little things like that or pilot that you can do to kind of diversify your revenue streams. So when we think about revenue cycle management as kind of a whole, so what are all the clinical and administrative functions that go into driving cashflow and profitability? So, right, so you're contracting, you can't just accept every insurance, especially if you're a new practice, really important for you to understand what it means to have a managed care or an HMO plan that you probably can't see the patient unless you're their PCP or you really are in network. So how is your intake team screening for that? A lot of these patients too, that are even on Medicare Advantage plans still think they have Medicare. So on intake, are you collecting demographic and insurance information and verifying that before you go out to make a visit, before you go out and start that care relationship, making sure it's an insurance that you can take and actually be paid for before you start that patient relationship. EHRs make this really easy, usually with a real-time eligibility verification. If it's a plan or a managed care plan that you're really not sure about, it's worth that call to kind of verify before you start providing services. And especially if you are using maybe a third-party billing company or a vendor, are you getting feedback from them? Are they meeting with you on a monthly basis and going over denials and which claims are resubmitted or what your average time to payment is for different payers? So you can really keep a pulse on that. And you can negotiate with your payers too. Try and look for annual contracts that could be renegotiated based on the cost and the quality of services that you're providing. And again, they've never been more open to listening to home-based care and that conversation and that door opening is a lot easier experience, but I really can't highlight the importance of a strong intake process that impacts us directly. And again, that's kind of, I got ahead of myself here a little bit too, but the average cost of a denied claim just to even process that is about $25. That takes a person and a lot of time and resources. So what are you doing to set up your billing and coding and processing on the front end to make sure that you're minimizing denials, you're addressing issues when they come in, you really understand who your payers are and what your contracts look like, and then you understand what expenses you have. Of course, you have your people and some infrastructure and overhead, but don't get yourself into a complicated vendor contract that is multiple years, very expensive for a service that you're just trying out, such as telehealth or an RPM platform. Really be thoughtful when we're kind of negotiating these things. So when you're thinking about quality care and your standards, again, it's always gonna be this balance of efficiency and quality, but you never wanna sacrifice quality. So how can we be creative in thinking about that? We have telehealth available to us now. So which visits might we need to do in person versus what could we do virtually? How can we really encourage our nurses and our clinical staff members to work to the top of their license and to be involved in the process? And to be involved in care management and things like that. Thinking about more risk stratification and understanding when you need to be with certain patients more frequently than others. All of these things, we can leverage a lot of these tools in our toolbox that I've been talking about to help us provide the care at the right time and the right place for the patient, depending on where they're at. One of the things we get asked a lot, I wanted to give you guys a lot of examples of what caseloads might look like in home-based primary care. Again, this isn't saying that you have to do this, but we get a lot of questions of like, well, how many patients can a provider handle? And it's gonna be different if it's a physician, nurse practitioner, team combo that are co-managing patients. These are more independent providers managing those 200 patients all by themselves that they're responsible for and they are the primary care provider, but just wanted to give you all some data and some ranges that we've seen common. Again, those medical assistants and those coordinators can really help with that too. I talked about productivity a little bit. So these are fee-for-service averages based off the home-based practices that we're aware of. On average, eight to 10 per day is what we see. Generally, that's really only achievable if you have a really tight geography or you maybe have an assistant traveling with you. I will say if you have more solo responsibility as a provider or you're serving a more rural geography, I would expect it to be closer to five to seven visits per day. Some practices may wanna look at just weekly goals too, or have certain providers that prefer to work longer days on some days so they can have a little bit more administrative time or office time, if you will, at the end of the week to achieve their goals. So think about flexibility when you're looking at these things as well. The next couple of slides are just some visit dashboard examples that can really help you give a picture. The other thing you have to think about when you're hiring and you're thinking about FTE allocation is no provider works 365 days a year, right? We need off time, we need holidays. How are we gonna plan for that? Weather and things like that. So you can go one more, Melissa. Just wanted to give you kind of some snapshots of what it might look like, especially if you're sharing provider resources. Maybe they're inpatient or on service some days and trying to avoid those no-shows or those really low value, high cost impacts to your overall productivity and bottom line. So again, we talked about personalizing visit frequency and how you can supplement kind of in-person care, getting resources involved early. Dr. Siri talked about this a little bit too, but when you're doing that initial comprehensive assessment, when is it time to bring in home health? Have you connected them to community care resources or other social services? Do they need specialists? Can you collaborate with those specialists? And how are you really making sure that when a patient's in, there's some providers that are practices, excuse me, that will even mark in their EHRs through a tag, if you will, or a flag or a different color or a rating within their EHR if the patient's high, medium or low risk so that they can drive interventions and talk about those patients more frequently and make sure that they're getting the resources that they need. The other thing that we don't do the best job about thinking about, and Dr. Chang's gonna end our day with a really phenomenal session on self-care, but how do you set boundaries with your patients? I think you guys are all here and we're all going into the homes because you believe in the right care for your patients. You have that heart. You have that passion to this mission. You wouldn't be able to do this work without it. So it's really important sometimes for patients that don't have anybody else to talk to or anyone else coming into the home or you walk in and you're just so overwhelmed by what you're being asked to do that you set expectations and set fair boundaries for yourself and for your patients. So don't get into the habit of, you know, making those extra trips to the home to pick up their medicines for them. What's a medication delivery service or retail pharmacy that delivers to them for you to do that? Because it's a really slippery slope when your providers start doing that. Or, you know, how do you really explain what your practice is and what your hours are and have staff provide education to patients and caregivers about them needing to be there or confirm appointments before you're able to go out to the home? If you take care of yourself and set boundaries with your patients, you're gonna be a more effective provider for them. And it's important to kind of know when you need to ask for support or say, you know what, I think we need to tackle these three things today and then I'm gonna come back next week or I'm gonna come back in two weeks and we're gonna follow up and we're gonna address the rest of your concerns during that time. So boundary setting really plays into how effective you can be and your efficiency. But you wanna be careful with home-based populations especially that you don't stretch yourself too thin or start doing, you know, things that really aren't within the scope of the medical care you're there to provide. We talked about kind of, you know, staffing and productivity, what are some other expenses besides your people, of course, you know, technology and payer contracts, pay really close attention during credentialing before you sign contracts, what are their fee schedule rates, is that above or below what you would get from Medicare. Are you trying to renegotiate are you really, you know, pitching a pilot to them or partnership conversation because you have a solution to their expense or their costs so really be thinking about those things, and how you can kind of have the greatest impact but also be paid appropriately for the work that you do. So if we're thinking a little bit about operating procedures, you've got to have a sound intake and registration process Dr Siri mentioned she has a, you know, an intake coordinator, if you will, or a set intake person that's gathering all that information, you're going to need someone to route and schedule patients geographically for your providers. You know, what is that interdisciplinary team meeting structure look like we'll talk a little bit more about that tomorrow but how is everyone communicating with each other. What are you know what information is being collected before that message is just passed to a provider and trying to decrease that burden. You know, really understanding when we say standards of care are there certain things that are done for every patient like advanced care planning and making sure they have a POA and post on file and going over things like that certain screenings for new patients that are being done consistently that you have that after hours support that you know how to bill and code appropriately, and that you're providing accurate or ample training and kind of opportunities for your providers and your staff, maybe you have an office coordinator or someone in an administrative role that has a billing interest and it makes more sense rather than you continuing to outsource that to invest in your team and training for them to take some of those functions over. So be thoughtful we talked a lot about EMR and that is what the setup is. One thing if you're still in the negotiating vendor contracts to how much training and like live support you have from a person, or and or when you know asking them what it would add things to really getting into those conversations before you commit to with a vendor about what kind of training and support they're going to have and how difficult it is for you to customize templates and reports and things like that when you need it. And equipment in the home, you never want to have too much right so try and keep your provider medical bad as late as you can keep extra, you know, non sensitive equipment that doesn't need temperature control maybe keep an extra box of supplies in the car, or, you inventory management system in place. So you can understand how to restock things appropriately for your providers and so they have what they need before they go out to the patient's home and reviewing that chart ahead of time is going to help you do that. And thinking about budgeting to there's a difference between where you are right now and where you are in five years so you know you really do need to take the time to say what's my expected volume of patients and what do I expect this year, and next year one to three versus a five year plan, especially if you're approached about a partnership opportunity to take on a bulk amount of patients at once, you know, do you really have the staff and infrastructure in place to be able to deliver on those results and always have a kind of growth and, you know, strategy in mind and how you're going to continue to evaluate your revenue to expense ratio. You're going to need to find the people find the right people that are the right fit that really want believe in this work and want to do this care, you're going to have more of those startup expenses at the beginning, you do need, you know, different supplies and bags and things that you go into the home that you don't have in a clinic or a hospital setting. You need to think about licensing and credentialing malpractice all of those fun things. resources and local SBA resources can help you. There's so many ways to use even virtual staff now, you know, so you have electronic phone systems and effects and really good internet access make sure you're kind of innovating with technology as we've kind of gone along to deliver your day to day business operations in an effective way and that gives your staff flexibility if they may be remotely located and things like that. So just expenses to consider but make sure you're doing it in an efficient way. So, when we talk about the importance of market early and often. Again, a lot of people are worried that the floodgates are going to open here we are saying we're going to come to your home we're going to provide this awesome comprehensive care but it's a to understand I used to be surprised with the amount of time that I would have to spend on the, on the phone with patients kind of explaining services, even when we got a referral and I knew they really needed it because it's, it's uneasy leaving maybe that clinic PCP that you've been with for years or there's a lot of risk to a new partnership opportunity so really be thoughtful about trying to grow your program. Early and not kind of feeling like you're holding off because you're still working on all finishing all the operations and things behind it. You also have to understand if your patients needs are changing or if you're being asked for services that you don't have or you're seeing gaps of care because you don't have a behavioral health referral provider that you work with or things like that so really understanding what your patients needs are and how that's how your clinical model is going to support that and may need to adapt over time. So, you know, a lot of services may bring in, like I mentioned earlier wound care psych or just the most common, especially trained provider to meet that mean. You can expect people to just understand how this works either you know you need to have onboarding and training guides you need to have these documented protocols in you know documented and staff cross trained because what if that one person that knows how to do So really thinking about how you can document protocols you have adequate training, you're constantly innovating and looking for improvement improvement areas. I know one practice it's really big on quarterly team retreats, and they'll look at things like processes that they've changed or incoming call and triage messages and, you know, new assessments that they've implemented and how that's really going but they make it kind of a fun team building activities so that they're constantly really being aware of how things are working. You know, even silly activities to everyone, you know, getting sticky notes and what does the nurse do versus the front office staff versus the medical assistant and making sure there's not that appropriate overlap. Really making sure with geographic scheduling providers you have to give feedback to your team if you're being given a scheduled where you're, you know, driving back and forth or you're coming back to the same area and missing patients. You really kind of need to give that real time feedback if you expect quality improvement to occur, and making sure that you're continuing to build relationships with all of your partners payers included but your facilities, your home health agencies, anyone that you're working with how can you continue to build that relationship and build on the success together. So talking a little bit more about strategies for versus if you're a smaller program, or your new larger program so we've given you I think I mentioned that there's some sample job descriptions available to you. But if you're a smaller program, you're going to need flexible staff that can do multiple roles so medical assistants are great starting place, because they can help with some clinical support to the provider they don't have that triage and clinical decision making like an RN does, but they can really help with a lot as well as some administrative support. So you want to make sure that you're using this partner, rather than hiring a social worker at first, or be nimble with how often you're using your social worker on which patients, and then outsourcing and the beginning is a little bit easier sometimes and being responsible for all this functions in house if you really don't know what you're doing but just be careful when you're vetting those partners and making sure you're getting, especially when it comes to external billing companies your revenue cycle management that you're going to want to make sure that you're paying attention to that. And then finally, if you're a larger program, you're going to want to make sure that you're providing a lot of value based care. So you're going to want to make sure that you're providing a lot of value based care. If you're a larger program here's where you have opportunity to innovate or even in value based care you know we can. So it's the same care team taking care of it for the same patients and they get really familiar with them. Maybe you want to bring on more specialty services in house that could set you apart from your competition, or you want to, you know, even do a pilot with a pharmacist maybe there's one through a local ACO that you could do a poly pharmacy paperwork with or paper with or kind of project with. So really being creative about that. And then, again, making sure that if you are paying for third party vendors when does it make more sense if you have the right staff to bring those things in house so you don't have so much of that outside of expense. So thinking a little bit about your hiring to again what's the main goal and what skill set of whatever individual it is, do you need to do that. As your practice develops that may change, but really thinking about, do I need someone that's clinically trained to do these kinds of skills or do I not could I start with a more administrative person that I spend some time training on my standards and communication thinking about creative interview tools, you know you have competencies, and you know skills tests that you could do or, or letting them observe a day in the life of house calls and really understanding what it is. And then where else can you find your talent we know hiring is can be kind of challenging right now especially with kind of being a job seeking market. So what are ways that you can find the right people. I know a lot of practices to that have even had a lot of great partnerships with local colleges or nursing schools or schools medicine schools where residents or interns or people that need credit hours might be able to help out even just during the summer or busy hours so be really creative about how you can use your team. And then from a clinical competency competency standpoint wanted to give you one other resource and we can put this in the chat about what do you need from your providers and how are you really going to make sure they're the right fit for the role, especially thinking about the difference between palliative to full based home home based primary care. being that managing all the chronic diseases and having those, you know, difficult prognosis and palliative care conversations and goal planning and family and care conferences so how can you think creatively about really evaluating the people and making sure you're giving them the right training to do all of these skills. Again, just wanted to give you some concrete examples to go off of thinking about different staffing models and I'm going to point out just a couple of differences between so this is the health system practice health system has a little bit more shared resources where they have a physician medical director, a shared practice administrator. Most of the visits are being done by those nurse practitioners. They have some shared RN support that is doing triage and managing care plans and having all those conversations and then they have a lot more administrative support. This particular practice did use medical assistance that travel with the providers. Some home based primary care practices will have medical assistance or assistance go with the providers either due to safety and efficiency the medical assistant can drive the provider charts, and they can maybe see a few more patients per day. Others use their medical assistance and more back office roles and have a supportive kind of role in the office and let the providers do visits by themselves so think about what your staffing model looks like. For example, what's different here is they actually have, they use again more medical assistance, no nurses with this model. They found that to be a really diverse role that they've just worked very closely with and partner with their providers they also have scribes so I've heard a lot more about scribes or virtual assistance, they don't have one for every provider, but they are connected with it, then they rotate throughout their providers on certain days, and then they have kind of more of a specialized office coordinator role that's really responsible for certain patients and managing their paperwork and needs throughout the practice so scribes and virtual assistants are kind of some of those other non traditional staffing roles that you might want to consider as well. In terms of system practice again this one had our manager oversight, as well as patient service drafts and specialists that was just more of an administrative. They answered the phone calls handled the paperwork did the scheduling and the routing, you'll see lots of different titles, but they did invest in some additional reimbursement and billing coding dedicated staff as well. In terms of having employed social workers social workers I, you know, I'm probably their biggest advocate I can't stress how much of a difference they make. So when it makes sense to have them on staff, a licensed clinical social worker can also provide clinical services and bill for it depending on the state so I'm thinking about that, and what the different licensures are if you are going to hire a person like that. So that's another example for you to refer back to in your resources. This highlights, again, kind of that pod system so what I mean by a pod system is a panel of patients is assigned to the same primary care clinicians, the same nurse or medical assistant social worker care coordination, so they really get to know their patients they have a direct line of communication, you would have to have a way to track this. We've seen some really good outcomes when you start to think about kind of more centralizing patients with a core team of individuals that's consistent that knows them and is able to manage their care a little closer over time. So other things that you can think about for your clinical model we talked about in person versus virtual but especially in value based care maybe. How can you use nurses for chronic disease education or check in visits with more high risk patients. How can you kind of proactively think innovatively about using some of your staff if you have it. And have you tried risk stratification or using a tool that could be built in your EMR that you know predicts which patients are at highest risk of readmission, or even if you're not that sophisticated yet, are you doing a root cause analysis after hospital admission. During your IDT meetings are you talking about patients that were admitted that week or that month and then planning for the resources that they need. especially if you have a lot of programs, play around with some of those numbers to kind of gauge capacity to certain partners. And then when you are embarking on quality improvement, and again, this is just some framework, but be specific. What specifically are you evaluating? By what percentage should that always be done? And when do you want to see that improvement? And then keep a pulse on that as you continue to innovate and pick different QI projects per quarter every six months or whatever is reasonable for you. Sometimes when you're starting anything, just like Al related to billing and coding too, how are you gonna get your providers to buy into, how does this impact our patients? How is this impacting clinical care and outcomes? If you have limited resources, how can you make what you're asking your team to do feasible for you and not have anyone overburdened or have unsuccess? That comes down to the why and the entire team really being involved and being shared data with and shared outcomes with to say, hey, this is our why. This is why we're here. Here's the impact we're making on our patients' and caregivers' lives. Here's where I think we can improve and how can we strategize and do that together? And when you make them part of the solution, don't just say this is what we're doing and this is how we're doing it. Allow opportunities for that team feedback and team brainstorming. That can be really important. And then again, when you're kind of, I don't wanna say auditing, but when you're evaluating that, you can take a small sample of notes and see how many times those cognitive assessments were really done or what is your patient depression screening overall percentage look like and how much is that really being done or is it maybe just not being captured in the EHR? So you can identify these standard tools, use your technology to make it as efficient as possible, document it so that you can report on it, provide that training and education. Think of creative team outings and ways that you can make this fun for everyone to be engaged in that solution. And then make sure you're sharing that structured feedback on a consistent basis with the entire team so they really understand their part to play in the patient's care and what difference they're making in outcomes. I love AHI. IHI, excuse me, I think they're a great resource. They have a ton of information. Again, just giving you some tools for thoughts, PDSA cycles, all sorts of great tools they have out there. Talk a little bit about, I talked earlier about where we get most referral sources from. I would say you can think here about these non-traditional private duty caregiving agencies, adult protective services, linkage programs, adult daycare services. These are all areas that care for similar populations of patients that you may need their resources as well, but it's also a worthwhile activity for you to be networking with and thinking about that. When you go into these different conversations, you really need to be able to articulate the mission and vision and goals of your program. What patients are you asking for? Who can you really make this difference on? Why do they wanna partner with you and somebody else? What pain point do they have that you're a solution to their problem? And what do you need from them for the partnership to be successful, but also what do they need from you? And is that really a good partnership that you're able to deliver on? When you're thinking about kind of how you can prepare internally, what is your marketing and collateral look like doing some of those team scripting and role-playing activities? Are they all able to articulate the mission and vision and program and kind of are advocates for your brand, if you will? Especially when you're hiring new staff too, they might get some complicated questions from new patients. So even if you're not marketing and you're just talking about how your staff can position, what are the five things they should go over with every new patient before every visit? This is our hours, this is how you reach us. Do you have X, Y, and Z in the home? What kind of information can they be creating? I strongly recommend your intake questionnaire be in your EHR if you can, or at least have a guide for them. So they're documenting and capturing that information in real time for you. And then also keeping an eye on, where are your referrals coming from and what's the value of that new partnership if it is new? The other things you have to consider, again, from a quality standpoint, and if you're ready for growth and some things that you could look at when you're thinking about maybe hiring new staff is from access standpoint, how quickly can patients get into a new appointment? Are you starting to have a big wait list? Is that something you need to keep an eye on? What's your turnaround time look like for getting back to patients or even response time and answering the phones? Do your patients and caregivers, Dr. Siri talked about the standard question that's on those experience surveys of, do they feel like their questions are addressed? Do they have trust in their care team? All of those kinds of things. And then really being able to take time during those visits, especially when they're new, to build that patient and caregiver trust with their provider and their care team. I know some practices that really have a nurse or whoever's in that clinical care manager role call new patients after every visit. So they can say, I just wanna go over your care plan, introduce myself and our team, see if you have any questions, explain how you can stay connected with us. Little things like that, that you can make kind of more standard process can go a long way. Thinking about your talking points. Again, you provide comprehensive medical care in the comfort of your own home. It should be easy to understand for all different audiences. Alleviate burden of that transportation. Don't disclude that patient that says, well, I still get out monthly to go see my daughter or to go to my cardiologist. Well, do you have trouble getting out of your house? Are you not driving? Do you rely on others to leave your home? So thinking about those kinds of easy ways you can approach those conversations and then honing in on a team approach and that care team approach, especially when you have physicians and nurse practitioners. Physicians be advocates for your NPs and be able to say they're gonna be the ones providing care for you or coming in to see you, but we work really closely together. And my nurse is an extension of me. So he or she is the one that calls you back. We're collaborating together on your needs. You don't always have to have that phone call back from me. So talk up your staff and then really reassure the patient on how much that can be done at home. Those outpatient tests and procedures, EKGs, x-rays, mobile phlebotomy, all those things that we can do at home now. It's gonna be a little different, again, depending on who you're talking to. So if you're talking, don't forget about your outpatient PCP clinics. I only want your sickest of your sick. I only want that patient that you're getting nervous about refilling medications for because you haven't seen them in a year or two. I only want your, to those ED and discharge planners, I only want your high utilizers, those frequent flyers that aren't getting the primary care that they should be after follow-up. That's what we're here to take care of. We're a solution for that top 5%. How can we really make that burden or take that burden from you? Because we're specialized and we're the best at what we do. I will say one other comment on that. If you're part of a larger system, sometimes looking at no-shows too, no practice, like no-shows. Well, who are your patients with the highest no-show rates? Is there a reason for that? That could be another kind of unique talking point you get in there. Questions or comments? Okay. So you really need to stay connected when you're networking, have scheduled meetings, regular touch bases, think about what marketing tools are available to you. Keep an eye out for new construction of facilities in senior living communities in your area. Become best friends with those discharge planners. You can always encourage a payer or someone that's a bigger partnership, like an ACO to start with a pilot. Hey, let's pilot the home-based primary care and let's see what difference I can make with 100 patients or 20 patients even, or something like that. There's a lot of predictive analytic vendors out there now. So kind of making sure you're keeping up with technology and regardless of your practice structure, kind of thinking about which partnerships out there you could be a potential solution for. Make sure you have those budgetary assumptions and you're able to take on volume. Again, it's really easy to say yes, but if you can't back it up and you're gonna sacrifice access or quality, that's gonna be a problem. Patient turnover, just because of the people that we're taking care of, their age, their disease status, I think it's generally about a 30% mortality rate in home-based primary care population. So you have to have that steady stream of new patient referrals coming in over. Making sure your community services are aware with you and that you're able to tell your story both through patient stories and through outcome data. So kind of just summarizing everything we've talked about today, your product is your clinical model. What do you do for what population? What costs are you avoiding? I used to have a good mentor that says, somebody is saving money by the care that you're providing in the home. So who are you saving money for? The care that you're providing in the home. So who are you saving money and how can you benefit from those cost savings? Tailor that pitch depending on your audience and understand who your allies are. These are all things that you wanna consider. Again, Medicare Advantage plans have never been more ready to talk to home and community-based services providers. Also, Dr. Siri and I know talked a lot about this DCE entities, Primary Care First. You may not be in it, but all of that's public information. So who are the ACOs in your area? Who are the Medicare Advantage plans in your area that have the biggest percentage of patients? Who are the DCEs that might need other people within their network to partner with? So be really aware of that and kind of looking for your opportunity. Next slide. I would say the three things that you have to have is you have to know your patients. Where are you gonna get the patients and what population are you best to take care of? What processes and operations do you need to put into place to make sure that you're providing efficient, effective, and quality care? And then how are you gonna get paid for what you do? Patients, process, payment. I like to say these are the three Ps, if you will, and these are the three things that are really gonna make or break the success of your practice. So lots of different standards. We're gonna get into some more of this tomorrow too, but develop sound support and infrastructure and then maximize your team creatively. Think about different interdisciplinary team members and always be prepared to kind of tell your story in that value. And with that, I'm very happy to turn it over to Dr. Chang because I love ending with self-care and know he'll do this topic justice. Hey, well, thank you, Brianna. Hey, it's been a long day. I know, especially for those of you on the East Coast, my presentation is probably between, is coming up to dinner here. So I will hopefully make this entertaining and engaging. And I hope that you will be able to take care of a very important asset, and that's you. That's your providers. We talked about no money, no mission, right? But in this environment, I would say no provider, no mission, okay? We all know about the quiet quitting phenomenon or the great resignation that's going on and the stress in healthcare. So I want to give us, I want all of us to take a little time to reflect. I'm gonna do a lot of the talking. Next slide, please. But as I go, feel free to put in some ideas, some nuggets, some pearls that you have learned in your travels on how to cope with stress and burnout. We're gonna talk about empathy and sympathy. We're gonna discuss some of the common stressors for home-based providers. Yes, it's a different beast. And the pressures are not the same as say an office and so on. Talk about different self-care practices. And I would love to hear your comments about how to be resilient and how do we go about developing that. Next slide, please. I think we're gonna listen or watch a video about sympathy and empathy, right, Melissa? Yes, let me just, I have to reshare real quick because I realized I'm making a sound, so hang on a second. All right, now everybody should be able to hear and let's go. So what is empathy and why is it very different than sympathy? Empathy fuels connection. Sympathy drives disconnection. Empathy, it's very interesting. Teresa, why is empathy so important? Empathy is a very important part of our lives. It's a very important part of our lives. Teresa Wiseman is a nursing scholar who studied professions, very diverse professions where empathy is relevant and came up with four qualities of empathy. Perspective taking, the ability to take the perspective of another person or recognize their perspective as their truth. Staying out of judgment, not easy when you enjoy it as much as most of us do. Recognizing emotion in other people and then communicating that. Empathy is feeling with people. And to me, I always think of empathy as this kind of sacred space when someone's kind of in a deep hole and they shout out from the bottom and they say, I'm stuck, it's dark, I'm overwhelmed. And then we look and we say, hey, I'm down. I know what it's like down here and you're not alone. Sympathy is, ooh, it's bad, uh-huh. Uh, no, you want a sandwich? Empathy is a choice and it's a vulnerable choice because in order to connect with you, I have to connect with something in myself that knows that feeling. Rarely, if ever, does an empathic response begin with at least. I had a, yeah. And we do it all the time because you know what? Someone just shared something with us, that's incredibly painful and we're trying to silver lining it. I don't think that's a verb, but I'm using it as one. We're trying to put the silver lining around it. So I had a miscarriage. Oh, at least you know you can get pregnant. I think my marriage is falling apart. At least you have a marriage. John's getting kicked out of school. At least Sarah is an A student. But one of the things we do sometimes in the face of very difficult conversations is we try to make things better. If I share something with you that's very difficult, I'd rather you say, I don't even know what to say right now, I'm just so glad you told me. Because the truth is, rarely can a response make something better. What makes something better is connection. I love that video. As many times as I've seen it, it's still a good reminder and I still get some chuckles out of it. Any comments from our learners about that video? I think it's a good reminder. From our learners, regarding empathy, sympathy, the difference and how does that work into the work that we're doing? Brianna talked about boundaries. When we're at the homes with our patients, sometime it gets a little blurred. Just this past week, a patient asked us to go pick up medications for him. It is just down the street. It is really hot outside. He doesn't have transportation. He's running out of pills. Should I do it? How many times should I do that? That's kind of the internal conversation I have. And I don't know if you have experienced that in your travels. I tried to talk myself maybe into a different way of thinking. I use the LVAD analogy. LVAD is for advanced heart failure patients. I think of LVAD as a, well, now it's a destination therapy. In the past, it was a bridge to therapy, a bridge to a transplant. So maybe I could possibly do it this time as a bridge to destination, but I can't be the destination therapy for all my patients and all their needs. The destination has to be something else. Social worker, pill packing, meal delivery, family member, or something else. Any comments? Next slide, please. So we all feel stress as we go about our day, whether it's work-related, patient-related stuff, or family. We're people. And so when we feel stressed, there's a reaction internally from our body that causes a response. But burnout is different. Burnout is more than just, I feel stressed right now or today. It's a long-term stress reaction that leads to emotional exhaustion and detachment, depersonalization. And you feel like I haven't done anything, right? And maybe you have taken on a negative attitude towards your work. And as we all know, burnout is a public health crisis in this country. Next slide, please. This is just a slide from, I think it's from Medscape. You can look at the specialties there in terms of burnout rates and their specialty. And primary care providers, nearly half of us are on the edge, thinking about slowing down, thinking about urgent care, thinking about the long-term effects of burnout. Slowing down, thinking about early retirement, or even seeing less patients, going to part-time, and so on. What I'm saying, it's nothing new to, it's not news to any of us, right? So how can we mitigate some of this? I have one more slide. Next slide, please. That Dr. Suri talked about earlier this morning about the study that was published, I think this is from Cleveland Clinic. But anyway, for University of Chicago, there it is, Hopkins and University of Chicago. It talks about almost the 27-hour day, right? And those of you who are full-time clinicians, you know, it's just like, yeah, it's about time somebody recognized all the work we have to do to not only care for our patients, make sure the care gaps are being addressed, make sure we do all the screening, do all the coding, and spend time with our family members, update them on this situation, and it goes on and on. And to do that, it's really, really demanding. Again, not news to those of us in the trenches, seeing patients day in and day out on a regular basis. Next slide, please. So we have identified, again, I would love to hear comments about some of the top stressors of being a house call provider. One of them can be mediating family conflicts. Remember, I'm in the bedroom or the living room or the kitchen of the patient and their family. This recently, I don't know how many, I would just say, I don't know, six or seven, Italian family members around grandma. And we talked about goals of care and maybe hospice should be involved and so on. And I will probably say maybe two-thirds said yes and one-third said no. And the exchange, and it became heated, right? And I'm the provider. I'm in the middle of this and trying to not only deliver care for the patient that I think she needs, but also at the same time trying to manage this family meeting without the support of say another provider, okay? So family conflicts, being home alone. I think that's, I think it's unique to what we do. EHR, right? I don't know if anybody really loved their EHR. And then we have prior authorizations, paperwork, handicap parking, paperwork, FMLA, and it goes on and on. Financial pressure. We talked today a lot about billing. You gotta bill this, you gotta capture these codes. There's that pressure for us to do more so we can be reimbursed, whether you're under fee-for-service or going into value-based care. Patient adherence. The analogy I often use is, this gentleman with terrible COPD, and you know what I'm gonna say, he keeps smoking. It's like, no, sir, you're gonna blow up the house. You know, you got, you're using oxygen. So adherence is an issue. It could be non-intentional non-adherence, right? It could be a literacy thing. Just this past week, I saw a patient, I can't show, it's on my phone. I took a picture of it. I'll show it at some point in the future for teaching. In a pill bottle, they actually took something, I don't know, something hot. They actually melted a hole in the side of the pill bottle so they can get the pills out. And through a translator say, you know, why are you doing this? I didn't understand. They didn't know how to open the bottle. So the instruction is clearly written on top of it. There's a little tab you press down and you can easily twist it, but it's in English. And when I went to the home, we talked about medication management and so on. When you go into the home, you have the privilege and the opportunity to talk about adherence and you demonstrate that for the patient. And they were so embarrassed. And that was such an easy thing. And then yet they didn't quite know how to do it. So adherence could be intent, if you want to call it an intentional or some other factors. Scheduling and logistics. Brianna talked about that, you know, time to first visit with a patient, TCM visit. My office is like, you know, Dr. Chang, why are you changing your schedule again? So there's that education about, hey, you know, I need to bump Mr. X so I can see Mrs. Y because she's a transitional care visit and I need to go and tuck her in to make sure things are taken care of. She doesn't bounce back to the ER and so on. Yeah, I'm seeing chats there. Expectations, huge, increasing productivity, right? We're also, we walk that fine line. And, you know, me as a leader of the practice, I walk the fine line between, oh, we got to keep the lights on. We got to go, we got to see more, take care of our patients, keep our quality and our satisfaction up and maybe pushing too far and then they walk out the door, right? And there's a comment about turnover. You know, somebody asked me a couple of weeks ago, you know what keeps me up at night? It's staffing, it still is. I got emails about this and that just today. It's staffing and retention. That, you know, we are so lean and if something else goes wrong, it's like, oh dear, we're in really a difficult spot, right? Reimbursement, I see the comment there. Ongoing, ongoing stressors for us. Next slide, please. And I love the comments, thank you. Keep them coming. So what happens to burnout? What happens? We tend to think of burnout just like me, right? What happens to me? But obviously there's an individual me outcome. We talked about that already. Depression, exhaustion, depersonalization, detachment, et cetera, et cetera. And then there's the patient outcome. I don't care about what I do. There's lower patient satisfaction. The quality of your work is less, right? When you're not focused, you're depressed, exhausted. You run the risk of making a mistake. And then there's the system outcome. We never get better. We can't move forward. There's always this turnover, right? I'm out of here. I don't need this, okay? And then the system has to reinvest money into hiring somebody else, training and so on. And all that period of time, you're out of a provider that our patients need to see, to take care of them. So a lot of innovation can be stalled because I'm always thinking about something else, like how do I keep my team happy? How do I keep people here and so on rather than focusing my attention on maybe growing the practice and so on. So there are multiple levels to burnout outside of just Paul Chang. Next slide, please. So what are some coping strategies for minimizing burnout? Again, I would love to have other people make comments here. Having joint visits to manage tension or maybe a difficult neighborhood that you need to make a house call to a patient. Having templates to help with the documentation burden. But on the flip side, understand, I'm a little OCD. I've actually had stopwatch or whatever. Timing myself in terms of how long I need to pre-chart, to preload labs, to do this and that. So I tried to build into my schedule and my day the amount of time it takes for me to do paperwork, electronic charting, so that I don't feel such tension when I overload my schedule. Financial model, obviously watching your overhead and pivoting to a value-based arrangement. For example, if you're paid on a per member per month, as Dr. Sirian mentioned, rather than a fee for service, I think that model will take a lot of the throttling or the pressure off my back in terms of, you gotta see this many RVUs, you gotta see this many patients. It's helping me think about, rather than how many patients I need to see today, value-based would encourage me to say, who needs me today that I can really make an impact rather than just pure volume, okay? Dr. Sirian and Brianna talked about team, the 26 hour day, I think that could be reduced significantly if we had team members to help us do our work, social worker, pharmacist, additional medical assistant or nurse to help unload some of the work that's been placed on the provider's shoulders. And then having administrative support, having a good relationship with your administrators. Their job is to help me understand the financial pressures and so on. And my job is to hear what they're saying and have a relationship with them, but also to educate them on the challenges that we face that squeezing in another patient may not be the best thing for the practice. Next slide, please. So resilience, how do we build our resilience? The people that do home-based care, we are mission. Many of us are mission driven people. We love what we do. We wanna help these patients who desperately need ongoing care. Without us, what do they have? They have to use the emergency room and a terribly broken health system that give them fragmented care. And patients don't want that and we don't want them to have to experience that. But to do our work as mission oriented as we are, we need to build some cushion, some resilience, be able to bounce back from the demand of our day, of our patients and so on. So I'm gonna, you can see the word cloud there in terms of how to build some of the resilience and so forth. I would highlight maybe a couple. Maintain that purpose, that higher calling, why we are doing what we're doing. It is very easy to get bogged down into the money. You know, I go there a lot. I look at the spreadsheet and so on, but I think it's important for me to pull back and say, you know, what is the bigger picture of what we are doing, what you all are going to be doing with your patients. Having a community, it's huge. You know, we invite you to be part of ACCI's community. I've often said you get knowledge through a lecture, but you get wisdom through a community. So I encourage you to get involved either locally with your own work group or with a larger organization like ACCI, where we can support you in the important work that you're doing. Being flexible, we're gonna go through changes. Who knows what this economy is gonna do, what the next pandemic is gonna happen, when is that gonna happen? Having the spirit of flexibility, but also keeping up with your skills. I think there may be less tension and stress if you're confident on how to manage. We'll talk about that tomorrow, the top five, you know, dementia, heart failure, COPD, CKD, diabetes. Having confidence in managing these multi-complex patients at the home can also build some of that resilience in yourself. And then again, having some time for yourself. Next slide, please. And I don't know what that means for you in terms of time. We do race throughout our day, especially with me under fee for service. Sometimes I feel like I am racing through my day, got to get to the next appointment and so on. But we all need that period of rest and recovery. And again, I don't know what recovery looks like for you, you can Google this on the internet, recovery for people might be classical music, it might be a mixed martial arts, it could be a rowing there on the lake, on a peaceful lake or running on a trail, whatever that may be, you need to fill your own tank after the race, you rest, you need to fill your tank, get connected with a bigger purpose, that mission again, so that you can be ready to do this again tomorrow. Because our patients need us, our healthcare in this country, they need us. And I'm not trying to be grandiose or dramatic, you saw the numbers that Dr. Asiri projected on the slide about the aging population, about the paper that the perfect storm that Dr. Cornwell talked about, the need for our service is just gonna increase. And we need to take care of each other, we need to take care of ourselves because we already don't have enough workforce. And if those who are doing it decides to check out, and that just is not good for our patient, it's not good for our country. Next slide, please. Some takeaways here, remember empathy, we need to have that connection with our patient rather than having a glib or that at least answer, at least you can have children. We need to stay away from that kind of thinking. We face many similar challenges as a office doctor, but there's some unique situations and demands that we face when we step through the door into a patient's home. And don't forget taking care of yourself. And I'll just say it again, no people, no mission, right? We need to remind ourselves we're part of a bigger cause, we're gonna work hard, but I'm gonna find time to recover, refill my tank so that I can keep going and deliver the care our patients need and enjoy my work. And that's it, be happy to take questions, comments. Yeah, this is actually, I just have a few more housekeeping slides at the very end, but this is the time we wanna kind of open it up for your questions to our faculty. So, Kim Baxa, thanks you Dr. Chang, was an awesome presentation. All right, so what burning questions do you still have about the topics we've discussed today? And you can feel free to unmute and just talk to us too. And while you're considering your burning questions, we have a very important question that we wanna have you answer in the chat. Oh, thanks Carl, so no questions from Carl, but here's a question for all of you. Please put in the chat at least one thing that you are especially glad you learned today. If you've been taking notes on your learning plan, you might find some insight there, but please put in the chat one thing that you are especially glad you learned today. Cause we'd like to hear that and kind of use that as a little bit of a kickoff. I really appreciated everybody that shared their stressors in their job and scheduling and logistics came up, staff turnover, the recruiting challenges, it increases because of inflation, flat reimbursements, late referrals to hospice, no Medicare reimbursement for palliative care. Certainly managing expectations of the patient or family and maybe even managing expectations of your team, your providers and your staff. Increasing productivity of the team during this difficult time, right? And encouraging in-person visits versus telehealth given the gas prices. So I really, I'm starting to see the items in the chat. Thank you. So about, you've learned about the extra billing codes for home-based programs. Janine, that's great. Nuances of value-based care. I love this, the good, bad and ugly because yeah, I mean, I think all of those are true, right? Lori says, I now have a better understanding of home-based primary care and I'm excited to learn more. So tomorrow, just a little preview of what's coming tomorrow. We're gonna start out our day and I'll get to this in a minute with the logistics, but we'll start out tomorrow at 10 a.m. Central, same time as we did today, same Zoom link as we used today. But our first session will be from Dr. Aaron Yeo on leveraging data analytics for growth and quality improvement. So speaking to those market analysis reports that you receive. Then we're gonna have a session on HCC coding and risk adjustment. So you heard Brianna and Dr. Suri kind of allude to that today. So we get more into the details tomorrow. And then we have a couple of very clinically oriented sessions because we wanna really help you understand clinically what's involved in providing this longitudinal home-based primary care. So the art of managing multi-complexity. And then we have a very interactive activity for the end of the day. It's a simulated house call. You'll go on three simulated house calls with very realistic patients in this space and give you a chance to develop care plans for those patients. And then code and document the visits as well. So you can look forward to that. And then Brianna also has another very meaty session on optimizing daily operations and covers a lot there. Let me see. Do any of our faculty have any other kind of wrap up remarks for today? Well, I just wanna thank everybody for attending and I hope that today was time well spent. I'm looking forward to tomorrow and we can get into more, give you kind of an experience of what it's like doing a house call. And as Melissa said, how to manage these, how do you juggle all these multi-complex conditions with competing interest and so forth. So really looking forward to it. I do have a confession about the self-care thing. When I give the talk, it's just like, Paul, you need to do more self-care. So just because I gave the talk, that doesn't mean it's just like, I have arrived or anything, I'm far from that. I have not arrived in any way. I'm on the journey with the rest of you. Work in progress, Paul, work in progress. I need a reminder in terms of, I need to refuel. Yeah, I'm not gonna stand in between anyone and happy hour at the end of your virtual day, but thank you all for being here. I'm excited to have some opportunity tomorrow to kind of just get into what this really looks like now that we talked about the foundation. And yeah, I encourage any questions you think of overnight. Let us know how we can make the most of this so that you all leave here feeling like you got what you need and we're here to support you along that journey. Thank you, everyone. Yeah, and so if you completed a learning plan, go ahead and submit that to us for day one. You can start another one tomorrow and day two starts tomorrow at 10 a.m. central time using the same Zoom link as today. I wanna just recognize Dr. Suri who she will not be with us tomorrow, but she's put in the chat. If you have questions that emerge like you're going to bed tonight or you're thinking of a question for her or tomorrow, go ahead and email me or education at hccinstitute.org and we will get that question to her. And of course, then tomorrow we will welcome back Dr. Chang and Brianna and Dr. Aaron Yao. So thank you all so much. And thank you to Sarah Sharp at NPHI for helping I see that you just posted the comments. So thank you to NPHI for working with us on this workshop. All right, we'll see everybody tomorrow, 10 a.m. central. Thank you.

Melissa Singleton

Chief Learning Officer

workshop

CME

CE credits

home-based care

primary care

value-based payment models

documentation

coding

telehealth services

value-based care

productivity

revenue cycle management

personalization