Good morning. Good morning. All right. We are looking forward to getting started. People are filtering in. We'll give it just another couple of minutes. Let people filter in here. Welcome back for day two. Tasha, I love it. You made more room in your brain while sleeping last night. Okay, good. Because it was, it was a lot, wasn't it? And so I really, I really appreciate that. And just a reminder, you know, because some of you messaged me, oh, I've got to leave early or I've got to go see a patient. And we did record all of yesterday's and we'll be recording today's. So if you want to go back into the HCCI Learning Hub, it should be published as early as next week, you know, where you can go and you can find what you missed and just listen to it over again. We also uploaded a copy of yesterday's slides into the HCCI Learning Hub. So you have that as well. And at the end of today, we'll publish today's slides. So all right, well, I know people are still kind of filtering in, but let's get started. And this is my official welcome back to you. You may remember, long time ago, yesterday morning, we started out asking everybody, what are one or two things that you hope to get out of this two-day workshop? And so here are some of the things that you shared with us. This is a good check for our faculty too, you know, to make sure are we hitting the mark? Are we getting you the information that you came here looking for? And throughout today, if you feel like you are still having some burning questions that are not getting addressed, please speak up. You can either private message me, any of our faculty, you can put something in the chat for everyone, or you can raise your hand and unmute and tell us what it is you're looking for. But we heard, I want to know how to grow our program, whether it's home-based primary care or home-based palliative care. Some of you were just looking like, what is home-based primary care? What are, how do I do it? How do I set it up? Or I have questions about EMR, workflows, documentation, actually, documentation, documentation, documentation, because we heard a lot of questions about that. Some of you said, I just want to be able to continue to support our community in the best way possible. And so we've got that reflected. Talk about being part of ACO reach, growth, expansion, not recreating the wheel. I thought that was really profound. And, you know, certainly in this time of limited resources, you know, you don't want to, you know, spin your wheels doing something that's already been pretty well defined and developed. And so how, what can you learn from other programs that are doing what you want to do really well? And then, of course, value-based care and that transitioning from fee-to-service to value-based care, or being able to navigate if you're in a place of having to be in both worlds, how do you do that successfully? So that's what we heard from you yesterday. If there's something else that you want to add, put it in the chat, and we'll make sure that we address that sometime today. And then at the end of yesterday, this was always one of my favorite things to do, to ask, what is one thing that you are really glad you learned today, which was yesterday? And so some of the things we heard, billing codes. So that's a big shout out to Brianna, who, my goodness, I've worked with her for five years. And if I even know 10 percent of what she knows, I consider myself pretty lucky. But she's got this wealth of knowledge to share about that. Nuances of value-based care and just a home-based primary care, what is it? How do you do it? And then Dr. Chang says about the value of getting wisdom from a community, because that's what we are and what you are in your NPHI community, that there's wisdom to be shared and received in that community of programs. So I thought that was really profound and resonated with at least one of you. You really felt glad to learn about partnership opportunities, again, about those documentation requirements, including CCM was particularly named. And you mentioned extended billing information. Also, identifying what some reasonable goals are for home-based primary care programs or home-based programs and to be intentional about how to hone in and achieve those goals. And then we heard someone talk about logistics for scheduling. So, again, really appreciative to hear that some of those things that we talked about yesterday resonated with you. So here's our agenda for today, and we are covering a wide range of things. We're going to start out, as I shared with you, Dr. Erin Yao is going to be talking about those market analysis reports that you all got and helping you understand how do you use this? How will the data analytics that have been provided to you really help you achieve your goals? And so he'll be sharing that and demoing some things for you. Brianna is going to talk about HCC coding and risk adjustment for house calls. Dr. Chang is going to talk about multi-complexity and some of the top four conditions that we see in this patient population and some strategies, best practices for managing those. And after lunch, Brianna will come back and talk about optimizing the daily operations of house calls. You know, if you wanted to know a little bit of details, because that's kind of a nebulous title. I know she's going to talk about front office, back office, the various types of staffing roles, the people's processes and technologies that are important for that. And so we're going to dive a little bit more into the details of those things. And then our last two hours is very interactive. So I just want to be I want you to be prepared that we're going to go on three simulated house calls with three different patients who really reflect and represent the patient population we see in longitudinal home-based primary care. And and then you're going to get a chance to develop care plans for those patients. And and you'll do that under the facilitation of Dr. Chang. And then at the end, we'll ask you to also let us know how much you code these visits now and and Brianna can can help facilitate that. So we've got a full another full day, a reminder about your learning plans. These these are learning plans that are useful for you for taking your notes, but also be sure to turn those into us a copy so that we can get some insight into the things that you're looking at, the things that you're wanting to investigate further. You can email those to us at the education at HCC Institute dot org, and you'll be receiving reminders about how to do that. All right, so I wanted to just pause before we dive into our first session to remind you that this workshop is not the end of our relationship with you all. I want you to know what comes next. Part of your package included HCCI being able to lead with you to one hour individual sessions with your program. And that's whoever you want to include. It doesn't have to be the people who it doesn't have to be only the people who are attending this workshop. You can involve others from your program as needed, but we want to sit down with you virtually and begin to really assess your current needs and your program goals to discuss some strategies. Initially, some strategies that your program might want to consider and explore and then what action steps you might be able to employ that could be directed at improving your operations, your workflows, your productivity. And and so what's going to happen after that first strategy session is our experts will kind of go away and take into account everything that they've learned about your program. And then on the second session, we want to come back to you and and provide some really specific strategies that we feel would work for you and and also provide an individualized step by step approach for achieving whatever the goals are, whether it's launching a new service line, enhancing your clinical care, improving your patient and caregiver satisfaction or transitioning to value based payment arrangements and demonstrating the value that you bring to to the payers. So be expecting that we will be reaching out to the person who purchased the package from your program. So that one main contact to try and get that scheduled here in the next several weeks, that first session. All right, so before we move in, are there any questions about what I've shared in the opening? Any questions about where you go from here? OK, all right, well, remember, the chat line is always open, and with that, I'm going to go ahead and turn it over to Dr. Aaron Yow. I introduced you yesterday, Aaron, but let me just also say Dr. Aaron Yow is the research director at Home Centered Care Institute. He is a prolific author of numerous research articles that have been published in places like JAGS and Health Affairs, and he's really expert at leading his team of data specialists and data scientists in taking raw data and making it very usable, very actionable for programs like yours. So, Dr. Yow, take it away. Thank you, Melissa, for the generous introduction. And good morning. Hello from Richmond, Virginia. I know we have some friends from Virginia. So hello, hello. And I want to say hello to Tasha. Hello, Sarah. Hello, Angela, because you have video on. So if you have video on, you're probably looking at me. So I have a beautiful flower from the garden, and you see our guide dog puppy. So we're a guide dog puppy raiser. So we raise guide dog puppies so they can serve people in the future. And this is also a purpose of HCCI. We are here on a mission to advance home-based, home-centered care to serve more people and improve quality. And I'm an academic, so I'm not a clinician like you can help a patient directly. I dreamed about it and even got a degree in nursing, but I probably already forgot everything I learned. But so our team has got some skills in data, so I'm ready to talk about the data we have created. Hopefully, it will help you to grow your program or help you to improve quality or help you basically be successful in the competition or meeting the needs in your service area. And we are, we're actually pretty cool because we're a CMS innovator. I didn't put it up on the slide. There are not many companies or organizations in the country have a status called CMS innovator. We, so the innovator status and license, we have the access to the 100% Medicare claims and Medicaid claims. So you can do a lot of analysis with this massive, massive data. We're not talking about gigabyte or terabyte. It's even bigger. I don't know if you're familiar with all the, all the B's, but it's a huge, huge data covers. We have access to data covers over 200 million life years in the U.S. So that's what we use to create a databases, national databases on home center care, including home-based medical care, hospice, home health care, hospice, home health. And we are also creating databases on, I call this connected care. So like CCM, chronic care management, remote patient monitoring, et cetera, or telehealth. And today we just want to show you a little bit about our home-based medical care database. And here we are only showing you the essential data, like the report you received. I call these are essential data points or measures for, for your program. For really very large companies, they will like to get very comprehensive data. We have a different version for them too. But if you have a certain, you know, data needs, we can talk about it. So please, please ask questions. If you can think of anything you think that can be answered with data from CMS or other data sources, or just some crazy idea and you want to throw out and happy to explore. So you can stop me at any time and happy to address your question, or we can have a discussion. And with this massive database, so we identify over 30,000 physicians, nurse practitioners, physician assistants have done, you know, a lot of research and done home-based medical care or made home visits or assisted living facility visits. I can tell you, many of them have only done a few in a year, like in 2021, but there are thousands of them have done hundreds of visits a year or over thousand visits a year. Okay. And also from this database, we identified TINs, you know, this employer IDs. So over 10,000 of them actually built for home-based medical care. But again, a large number of them, thousands of them, they have only done a few or dozens of visits in a year, right? But there are still a few thousand of them actually done hundreds or thousands or tens of thousands of visits in a year. So that's the data source or the data sets we have created. Now, if you have your market analysis report, you can pull it out or you can remember things from the report. That's great. And next slide, you can see different components of this report. Like I said before, we have more data, many, many more measures, tables, and maps, graphs than this list, but this is the essential data elements I put together for you. So the first part we're going to talk about are the home-based care supply. We're talking about home-based medical care and hospice. And this is home-based medical care. So here you see a few columns, which county it is, and then the name of the clinician. It looks like we have three nurse practitioners, one internist in California, and number of patients they have, and number of total home care visits. And I'll also provide you a median number of visits per patient. The reason I have this, it's a bigger median number of visits per patient. I mean, this person is probably doing more home-based primary care and palliative care than home-based or urgent care. So there are clinicians doing home-based urgent care too. Do you have any questions? I'm just putting into the, and I have a spelling error, sorry. In the comments, some of the use cases for each of these information so you can understand. Aaron, you agree this supply analysis could be helpful for the programs to understand their competition in their region. But it could be helpful for recruiting, right? Are there other use cases that you see or would those be the primary? And if you want to collaborate, you know, that's another thing, right? If you have a patient really far from you, you know, you are kind of want to focus on one area, one county. But, you know, there are someone else in the neighboring country and you can make a referral to that clinician. And if we have time, I can show you the interactive platform we have. So you can actually look at data from all 50 states. So you can do more with care coordination and hiring, right? If you want to hire someone with some experience, you have seen dozens of patients before or hundreds of patients before. Yes, we have these data. Because you can look at quality. And we also have quality performance data like their admission per thousand patients or ER visits, re-admissions and the total Medicare payments. We have the HCC score, average HCC score of their patients. See if they are seeing high-risk patients or, you know, medium or low-risk patients. Angela? Hi, Aaron. Thank you. And you might be going into this in just a few minutes. So forgive me if I'm jumping ahead. But on the reporting, we could just use the example maybe you have. I just want to clarify, these are just home-based visits, right? So these are visits being done either in the ALF, independent living or private home? Yes, it's a home, assisted living and group homes. Okay, thank you. And I'm sure you said it, but I'm sorry if I missed it. My other question on the second part of the data, the hospice data, how about that as well? Because it will say like a specific hospice name and then a number. Those are also provider visits at home? So you see, thank you, Melissa. And you see the column care provided at home, right? So if you multiply the average daily census with this percentage, you will get the daily census at home, basically. So the census is total. It doesn't matter if it's at home or hospital or other settings. Got it. Thank you, Aaron. And it's a great segue. So let's just talk about hospice. So there was a question, real quick, Aaron. Tasha asked if there's not many providers like on her report in her area, does that mean there's just not that many practitioners that are doing home-based medical care in her area? Probably. So our data, the report you got, the data is based on Medicare fee-for-service claims. We haven't put in the Medicare Advantage data there. Okay. Because we have a time lag getting the 2020 data of Medicare Advantage. There might be some providers doing business with Medicare Advantage, okay? Or they are clinicians doing business with the private payers, commercial. And how old is this data I'm providing you? It's 2021. It's very recent. However, I don't think, like, there are a whole lot of clinicians that are only doing business with Medicare Advantage, okay? If you don't see clinicians in your area from our report, I say probably there's just not many in your area. I mean, think about if you're in a rural county, think about the windshield time. It's not a whole lot of people want to do it. And I actually started a house call program with our geographer at the University of Virginia. You know, it's, of course, Charlottesville, it's kind of urban, but it's surrounded by rural counties. And sometimes we have to drive 45 minutes one way to see a patient. And so there are not many clinicians that are doing house calls in some areas. I know from your report, like Tallahassee and then Lexington, Virginia, there are just not many house call providers, right? Can I ask a follow-up question to that? So the other thing I'm wondering, like I'm looking at our hospice data here, and I know there are other hospice organizations that are operating in the area, but they're not showing up on this report. So I'm also curious if that may be because they're headquartered in a different county or something, so they're just not showing up. Are you in Tallahassee, Florida? No, I'm in Rockbridge, Virginia. Yeah, I actually also figured that part. I did some, you know, search on CMS website. You can actually find more hospice agencies for area because it's kind of also about how they draw the line, the radiates, right? If they can say this, the other hospice agency also doing business in this area, but what is the market share really, right? Is it big or is it small? And we're developing the hospice data sets too. In the future, we're going to have the market share of hospice agencies in a specific market or area. So this one, we use the headquarter address, okay? Okay. So you're right. This is the address of the headquarter, but actually we have a slide about next steps. One thing is about the market share of the hospice agencies in specific markets. But in the future, it won't be in PDF format. It's just very hard to navigate. It's going to be online web-based platform. Thank you. So hospice here, we're only showing you, I think, the essential data points for you, the daily census, percentage of care at home, and the net promoter score. You can think of that as a quality score. I don't know how many of you are familiar with the net promoter score, but in the startup world, it's huge. If you can have a score over 80, 85, 90, you can get millions of funding from investors. But basically, it's a calculation I used from the two questions from the survey data we got from CMS. But basically, a high score is better, right? You can get 200, but rarely you can see scores over 80, 85. Aaron, would you just clarify how old the data is? Janine was asking about that. I think it goes through at least 2021, but I thought... I believe it's 21, but I can double check. In the future, our development of data solutions for hospice, you're going to see 2022 data. But different data points have actually different dates range, like the net promoter score is from survey data. But for claims database quality measures, it will be 2022 and 2021. Let's see. Do you want me to go to the next slide? Yes. Tarsha said you like the PDF format? Just the data. I'd like to see this data for our organization. It doesn't matter to me what format it's in. The net promoter score and the percentage is interesting data. There are lots of use cases. Just like the home-based medical care, you can use this for competition analysis. But you can use this for benchmarking. If you're trying to build relationships with hospitals and other healthcare organizations, you want to show this to people. If you think you're the best in the market, just show them your market share, quality ratings, performance measures. We're the best. You should contract with us. Talk to geotricians and others. This slide is about demand. We use population-level data like the number of older adults, the number of the oldest. So you can have a general idea. If you have been in the business for many years, you probably have a good sense. If you just look at the number of 85 or older, you can take a percentage. You can probably calculate the total market size in a county quickly. Because you know the death rates in a county and for certain age range, age groups. If you think it's too hard to do, we're going to do it for you. We're going to calculate the total market size for a zip code, for a census tract, for a county in the future. So you can know potentially how many deaths there are in a county, in a zip code, in a census tract. And then use that historical data to predict how many of the deaths are going to use hospice. Of course, we hope more people can actually receive hospice. But we can use the historical data to predict or to estimate the total market size. And the table about disabilities, it's more on the home-based medical care side, not about hospice. If people have mobility challenges, of course, you would expect they might need home-based medical care, right? And other disabilities, of course. We also have frailty data too. Potentially frail people need home-based medical care. And again, it's going to be in our web-based platform. And in the future, we have data for all 50 states. But we're planning that platform. And in the future, there will be a fee with the subscription model. But I think the leadership will be happy to give you a discount. Okay. Tasha also asked, does the county information include the cities within? I don't know how. I know for most of the states, a city is part of a county. It's different for Virginia. I don't know, Tasha. It's an independent city. It's not in a county. It's weird. Because I know in Richmond, we have Richmond City, Henrico County. But I think Virginia is the only one that has got this unique relationship between county and independent cities. But I know there are only a few independent cities in Virginia. We can revisit that, Tasha. Yeah. Yeah. So Aaron will be attending your at least the first strategy development session. So you'll get a chance to ask him some more individualized questions and about your data as well there. So moving on to assisted living. Yeah. As we know, we all want to reduce our windshield time. If we do business with assisted living, we can see multiple patients at one visit potentially, right? That's why actually if you look at national data, the volume of visits to assisted living has increased exponentially. I think it doubled in a few years. But visits to private homes, state flat. And I know it's important for home-based medical care programs to build relationships with assisted living. That's why we're providing the data. And actually, my team is busy collecting data from all 50 states. Because this we have to get from individual state governments. So like for four programs here, we have to go to four states to get them. And then we're going to update this data. And this is the most recent data. You get their name, address, phone, and the number of pets. And for our online platform, we have space to show more data points like the contact person. For some of the states, they have the administrator's name and the information too. Okay, billing. I'm sure you already learned a lot from Brianna and Paul on the billing part. And I don't know a thing about billing, but we know our data. So we grouped home-based medical care programs by volume. And then look at their billing pattern. See what billing codes they're using to bill Medicare. And we also grouped them by the place of service. Is this private home or assisted living? It just gives you a reference so you can pick and choose the best billing codes you can use. So we have three slides. This is the low-volume programs. And then, Melissa, you can show. And then this is the mid-volume programs I call 50 to 49 patients. And then the larger programs. You see for larger programs, I believe they're doing more like lab tests, x-rays, et cetera. And Brianna shared here, you know, I mean, the way this is useful is benchmarking the level of service data, you know, to compare your billing pattern trends to other similar providers. You know, what potential revenue might you be leaving on the table that your competition isn't? And Tarsha, my colleague, and we actually talked briefly about using our data also to look at the denial pattern. This is a billing pattern, right? We also want to try to identify denials from claims potentially. So stay tuned. In the future, we might have similar data, but on denials. Okay, now it's a hands-on session. It's about catchment area planning or catchment area optimization. I don't know how many of you have used these online tools before. There are a few of them, but I just use this website. If you can just type this on your browser, we're going to do that, but I'm going to do a quick demo. So I'll stop sharing the slides, Aaron, and then you're going to share, right? Yeah. Let's see. Can you see my screen? Yep. I think I had a address before, copy, no. I think I used one of yours address, let me see. Since I'm at Virginia, I'm going to use Virginia address. Is that okay? Is it Lexington? Yes. Can you give me the address? It's Lexington, Virginia. Oh, it's like the street address? Yeah, the street address. 314 South Main Street. 314 South. No, sorry, it's 315 Myers Street. 314 South Main Street's a different business. 315 Myers Street. They're just two blocks away from each other. Either one would be fine too. Yeah, Myers, M-Y, no. Sorry. Myers, M-Y-E-R-S. Lexington, there it is. Third one, that's us. Can you give me a different address? And say we're driving, right? We're not biking or use public transportation. And then we put 15 minutes. Oh, sorry, I didn't know it's coming. Oops, sorry about that. But I'm just going to do this. Sorry, sorry. I don't know why it's asking me, it's, I was, okay, thank you. Do I have it right? Accent it. Oh. Sorry about it. It was all fine. Let's use my personal... Okay, so you can see how far you can go. If you live there, you know how it looks like. And then say you want to do 30 minutes. This is how far you can go. I believe it's, I can try another address. Do you have another? If like your clinicians are driving out from their homes, you can put their home address, right? Or you have multiple address, and then you will see actually the overlap of the catchment area. So you can optimize. If, you know, you have a small team, and I think you can do this kind of manually using this tool. But if we would say you have 20 clinicians, then we'll probably need computer to do some statistical optimization stuff and routing optimization. But if we have a few, I think we can do it to use these tools, okay? And let's see. I don't know if you have another address, but you said 314 something, let's say. No, that's the, you could try Covington. Yeah. That Covington address, that's another of our sites. Okay, can you just tell me the street address? Actually, I'm not sure what the street address is. It's okay. I'd have to look it up. It's okay. Okay, so I added another address and look at the coverage. So see how it overlaps. But of course, if you add five layers, it's going to be messy, hard to look at. That's why I said, you know, better to, if you only have a few clinicians, you can use this to do the catchment area planning. Okay. Okay. Do we have any questions? Okay, let's go back to the slides. Sorry. Lori was asking, the map in our docs is Chicago. Yeah, it was just for demo purpose. You all need to do your own analysis. I give you the link. We, the Chicago map is what we did. It's fancier. We put more data on the layers, but we can potentially do that. It's more complicated for your own work and planning. It's better to use these online tools. Yeah. Okay. All right. Super. Well, let me go back to sharing my screen. All right. So talking about referrals from home health. So these referrals are home-based medical care referrals, means house call programs, getting patients from home health agencies. Of course, house call programs also send patients to home health agencies. So it goes both ways. And we use some probability-based algorithms to identify home health agencies actually made a lot of house call referrals in each state. And you need to find out whether these home health agencies are actually in your area, and potentially you can build relationships with them. And we have similar data of referrals from like specialists or office-based clinicians, referrals from outpatient facilities, referrals from skilled nursing, et cetera. This is data on home-based medical care. In the future, we will offer a referral database about hospice referrals, basically, but it's not in your report or in this presentation yet. Yeah. So understanding where your referrals are coming from, where they can come from, some new relationships, new partnerships that you may want to establish is sort of the value of this part of the report. So then we have a little more information about home health as well as for partnership opportunities. Yeah. So if you start a whole house call program, you probably thinking of value-based care or just for patient care part for better quality, you always want to refer the patient to the best quality home health agencies. So we have some essential data for you so you know where are home health agencies and then their quality rating, satisfaction rating and admission rates. And in the future, we have more data points on quality part. And the CMS use some algorithms to measure quality. And they also take data from the OASIS and we will have that too. Any questions about the data on home health? Okay. Let's move on. Tasha. Yeah. I'm not sure that I'm following the percentage of hospitalization and what that's telling me. A number of hospitalizations of their patients, say if they have a hundred patients and the 14 of them had hospitalizations. Like during a year, during the year period or? I think during their service period, it's not, well. Or is that like an average or? Yeah. And I need to look at the source data, but I believe it's their service time or at our one-on-one meeting, I'll make sure I have the accurate answer for you. Sounds like it would be maybe an average during their home health episode for all of their patients. Of course it's average, but it's during their service time. During the period of their service. Okay, gotcha. Thank you. Yeah. I think before it's like a two months as a episode, right? Now it's a one month episode. I think it's depending how long, how many episodes of care they're getting. But I think it's during the service time. But even we don't know the exact meaning, but we know a large number is a bad number. Yeah. That was a great question. Thank you, Tasha. Next slide. Okay, this is a really the value-based care stuff. Okay. And this is about house calls, home-based medical care. In your report, we have data for state average, but for programs, if they have over 50 house call patients, longitudinal house call patients, we will calculate and create data of their program too. These are the data points value-based care care about. And we work with larger companies and they all want to look at these. If they are doing acquisition or they want to use their data to talk to payers or CMS, et cetera, these are the data points we're talking about. They're basically three or four types. One is the volume data patients you have. The second type or category are risk-related data. The second type or category are risk-related data. Means the HCC score. Okay. The HCC score is a frailty score. Frailty score is not really used in payment, but it's important for home-based care. So for HCC score, it's crazily complicated. They're prospective score, concurrent score. You need to do normalization, blah, blah, blah. Okay. So that's the risk level of patients. That's the second category. Then the performance data, one is on utilization-related performance data points and the other is costs-related performance data. So see the last three, the PMPM per member per month, of course, that's cost-related. And the utilization-related, you know, this admissions, hospital days, ER visits, SNF stays, et cetera. If you're going to do value-based contracting in the future, you'll probably need these to do benchmarking, to demonstrate your value, your impact, and compared to state average, compared to programs in your area, et cetera. And this is, I think, something valuable. If you have heard of ACO REACH, or before it's high-needs DCE, et cetera, we also have data like how many of your patients actually can be defined as high-needs and also using the CMS attribution method, how many of your patient can be attributed to your program and your clinician. It's all possible. It's just more customization, more analysis. Erin, am I correct that in each of their market analysis reports, the state average column is specific, like you provided them with the numbers for their specific state, right? Yes. Okay, and so what we would be moving towards is, you know, we would need to talk with you further to get some more information, but to populate that program column for you so you can benchmark your performance against the state average. Is that correct? Yeah, and also we need enough number of patients to do that, right? If you're starting a house call program, you're probably small. If you have 20 patients, it doesn't make a whole lot of sense to create this data points yet. So any other questions about the program profile and the opportunities here? I think this is a really good solid list of the metrics that, you know, even if you don't have the 50 patients yet, you know, or you're not quite sure. I mean, these are things that you would want to start measuring on your own and tracking. Yeah, some of the stuff it's almost impossible for you to calculate because you don't have all their claims. You know, it's like, what do you have from your EMR? Your records, it's like a snapshot of their care journey. That's the problem for most of you, unless you have a request to order claims from CMS, right? So it's some of the stuff, it's really hard for us to create it on our own. Yes, good point, thanks. All right, well, let's, this is the last formal slide, but we do still have 15 minutes, Aaron. So I don't know if you wanted to, maybe just, we could go through some of these items and then did you want to show a little bit? We want to pause to see if we have questions. I can talk about this, but I'd like to know if we have any questions about the report, about the slides we have talked about. And you can also let us know what other data you're thinking, you dream to have, right? And we'll figure out if we can get the data for you. I will let you think a little bit when I'm talking about this slide, okay? I know all of you are providing wonderful hospice care. That's why we have this slide talking about hospice-related data we're creating. So first of all, the referral sources, I know there are other companies selling hospice referral data. We will have that too, okay? So very specific at clinician level, at the healthcare organization level. You know, it's not just like who are actually making referrals, but I want you to know what hospice agencies they are referring the patient to, okay? So you know the referral, but also the relationship and the competition. And then the market share. So we define a market first, county or metropolitan area. And then we, as you know, the hospice agencies are doing business here, market share by percentage, right? For this county, how many patients getting hospice from you? How many, what is the number two, number three, right? And then we talk about how many, we're estimating number of deaths every year in a market and the historical data of how many deaths are on hospice. And then we estimate the total size of hospice market. And we have the performance measures, like you said, the NPS score and other things, ratings. And so you can benchmark and show that to stakeholder groups. And then I'm happy to provide the Medicare Advantage Penetration data at county level and their market share for your county, like which MA plans are the largest and et cetera. So these are just a few. We're developing and plan to offer to the market. To the market. All right. So any questions for Dr. Yang? You can reach me at research at ACCI email. so if you have questions later, okay, before the consulting appointments. Yeah, so research at hccinstitute.org. Tasha says this is going to be a service available to subscribe, purchase through HCCI. Yeah, just a little bit more about that because, you know, the kind of basic or the essential data in the PDF report is, you know, what we provided to you as part of this package. We've been on a journey at HCCI for almost two years now, Aaron, I don't know, two, a year and a half, it feels like two years, to build this platform called Aaron for Home-Centered Care, and, you know, that is the engine behind these reports, and Aaron has just been doing wonderful work in terms of building this out, integrating new data sources, and yes, it's ultimately going to be available to a market to purchase on a subscription-based model to have real-time access to pull your own reports and your own geographies, whatever you need, and so that's what I think he can demo a little bit more for you during the strategy development session, and I think we'll be able to show you even a little more information, you know, to answer some of your urgent questions, so we're not being coy about it, it's just still kind of in the development stage. Yeah, well, maybe just give a group a peek of some of the data. Okay, yeah, we've got about 10 minutes, so if you wanted to show some. Oh, I only need one minute. One minute? Yeah. Let's just look at it. Let me see if I have it right. It's here. Are we on this? Yeah, I can see it. And as you can see, it's all 50 states, and we're telling you about all the house call programs, and we have lots of filters. It's almost like you're buying something on Amazon. It's got a lot of filters, and it's a scatterplot to have three key measures, like the number of patients, volume data, and the PMPM adjusted for HCC score, so it's basically quality, and then the HCC score in color, so you know the risk level of their patients. So, these are programs, practices, so if you're targeting at a high-volume practice, you can go here, small, low-volume practices here, and of course, all their quality performance data are in the table, and you need all the risk scores, PMPM, PMPM adjusted for HCC score. We colored their quality measures just like your credit score report, right? If it is yellow, it's not that good. If it's a dark green, it's pretty bad, pretty good, right? You see, so we also have the 100 score ranking system, so, and lots of data, patient age, due eligibility, demographics, their chronic conditions, etc., etc., and we can add to this table. It could be really long, but we picked the most important ones, but that's just for a house call, of course. We will have a similar design for hospitals, for home health, for chronic care management, etc. Yeah, and so, as you can see, I mean, you know, part of the challenge is, because it's a lot of data, and it can be overwhelming for programs, especially when they're first starting out, and so, in curating the data that we did for your market analysis report, and walking through it today, our intent was to help you understand how you can immediately use the data that we're providing to help you achieve your goals, and then, as we speak with you in our, in your individual sessions coming up, you know, we can learn more about your readiness to, you know, use additional data, and talk about how you can leverage that, too, as well, to accomplish your goals. All right, so any final questions? All right, well, I want to, I put Aaron's email in the chat, so if you wanted to reach out to him directly, you can also go directly to me, or to or to research at hccinstitute.org, we can help you out with that. Thank you, thank you, everybody. Thank you, Aaron, thank you, and you'll be talking with Aaron again in your later sessions outside of the workshop. Okay. Enjoy the rest of the day. Enjoy. All right, well, so we go from talking about data around HCC scores to, okay, what do we do with HCC scores, or HCC coding? So, I'm going to ask Brianna and Paul to lead this session. Thanks, Melissa. All right, we're going to keep this engaging, and we're going to get you all chatting today at one point or another, that's my goal. So, Dr. Cheng and I are going to tag team this session on HCC coding and risk adjustment, so really understanding what is a risk score, what are some diagnosis codes, and making sure that you are common in home-based primary care, how do you really actually capture that for your patients, and make sure that you're not kind of missing out on opportunities. So, those are our objectives. We'll also talk about some strategies and how you can kind of implement this, and, again, it's a process continuing to grow. As we start, Melissa, if you can move one more, I think the graph doesn't pop up unless, yep, there we go. Thank you. We'd love to also hear in the chat what everyone's kind of experience or familiarity with HCC scores and risk adjustment is today. That'll just help us as we move along. So, there's multiple different risk adjustment models. What CMS is accomplishing by risk adjustment is trying to predict the total healthcare cost. It's not claims-based data. It's how much does it cost to take care of a patient based on their chronic diseases, and there are certain chronic diseases that Medicare predicts are more costly, and they want to make sure that those patients have appropriate resources. So, definitely most important for Medicare Advantage plans, but we're starting to see this, you know, PACE uses risk adjustment, all of the alternative payment models, mostly out of Medicare and CMMI. You heard Dr. Siri talk about, and that's kind of what this example graph is, is that actually drives your PMPM or your per-member, per-month payment in value-based care. So, what Medicare would do in that situation is actually look at your total patients and all of their HCC scores and then take the average, and that would determine what your payment would be for care management and for taking care of those patients based on their illness. So, essentially, all of this comes down to ICD-10 coding. Your patients are reborn every year. Risk adjustment is an annual 12-month calendar process where they're saying, okay, what chronic conditions do your patients have that Medicare uses in this algorithm that they predict are going to be more costly, and then that's tied to how Medicare Advantage plans are paid for their premiums. It's tied for how practices are being paid in value-based care, and it can also be used, as Erin talked about, with some predictive modeling and risk stratification of your patients as well. So, lots of opportunities. We're seeing Medicare use risk adjustment more and more broadly, but essentially, it's looking at all ICD-10 diagnosis codes within a 12-month calendar period and trying to predict how costly and how sick your patients are. Problem is, that comes down to coding, but it's the best way that CMS has found to do this to date. Next slide. So, you may have heard of RAF, the term RAF before. That's the risk adjustment factor. So, just so you understand, there's some things that are outside of your control and then some things that are tied to coding. A RAF score looks at some patients' demographics, male, female, age. Are they on Medicare because of a disability or because of age? That's a factor in their RAF score. All of their diagnoses, like I spoke about, I'll touch on what interactions is. Again, there's just standard methodology used within the risk adjustment model, and then what they updated as of 2020 is if a patient has at least four, anywhere from four to 10 HCCs, they're adding additional weight or additional risk for those patients having four or more HCC diagnoses, so four or more chronic diseases that they think really are reflecting risk. So, that's just how a RAF score is calculated and what they're looking at for these patients. So, we can go to the next slide. Again, these are just standard interactions. So, Medicare would look for when patients have both of these things, and it just is an additional weight or an additional consideration that they say, okay, this makes the patient higher risk. It's part of that RAF score calculation. Nothing you need to do other than making sure you code all the chronic conditions that a patient has. These are just so if you hear that term, interactions, you know what they are. Where it matters, and CMS is constantly trying to improve risk adjustment. How do we make this important or more meaningful? How do we make this more accurate? They know it's not a perfect science, but what they're trying to do is continue to improve on it. So, dementia as of 2020 counts as an HCC risk adjustment score, which is great. And then, all pressure ulcers are now HCCs, but they added the partial thickness one as well. Where you have to be careful is unspecified diagnosis codes. So, if you're, and especially when we think about that, you know, being careful not to just code signs and symptoms when we have a confirmed chronic disease, like Dr. Suri mentioned yesterday. If you told me the patient just had depression unspecified or just had mild cognitive impairment when it was really Alzheimer's or dementia, that's not an HCC. Medicare is not understanding that that patient has that risk, and then it's going to affect payment, and it's also going to affect the types of resources that that patient gets. They want to provide more quality, more resources to the sickest patients who really need it. So, this is just showing you some of the evolution of risk adjustment, but it really comes down to how specific are you being with their diagnosis coding? And all are you coding the actual chronic condition that's causing that symptom, if it's confirmed, if it's known, and you're treating that. Next slide. Just to kind of get into a little bit of the financials and kind of what makes the difference. So, let's say, again, these are kind of figurative examples, but the patient, throughout the year, you captured these diagnoses. Maybe you're really just focusing on, you know, you didn't capture any of their chronic diseases, and you were seeing them for acute visits for, you know, shortness of breath, let's say you coded that, or cold, acute, you know, and you weren't capturing that the patient actually had diabetes, heart failures, Alzheimer's. That makes a huge difference on the annual capitated payment that that Medicare Advantage plan or whatever kind of risk adjustment model we're talking about. Now, let's say you did capture their heart failure and their diabetes. You can see with a financial impact and how that increases. Let's say you did, in your annual wellness visit, the patient also has a toe amputation, and major depressive disorder, and a colostomy, and you did a really good job in capturing throughout the encounter, throughout the year, all of the chronic conditions the patient has, and those kind of odd but carries a risk factor ones like toe amputations or colostomy status. You can see the financial impact is significant. So, that's why it's really important. Again, you don't have to do this every time through every visit, but throughout the year that you're making sure you're capturing all the chronic conditions that the patient has, you're coding it to the highest level of specificity. If you're seeing them for a visit, and they have an exacerbation or complication, really, really important that you're coding those through ICD-10 diagnosis coding. And the EMR, you know, we talked about it being friend or foe yesterday, but we do have tools to make this easier for us. A lot of them have modules where it will show you which diagnosis codes are HCCs, create favorite lists for your providers. We're going to talk more about some of those strategies, but we can use our technology tools to do this. No one's expecting you to remember all of these off the top of your head, but what it is important is to kind of continue to educate your providers on how they can impact their patients getting more resources or their illness being appropriately reflected through their ICD-10 diagnosis coding. So just a little bit of an example of a patient case. Anyone know which of these diagnosis codes are HCCs versus which are not? I'm going to take a stab. I would love it. Go. The Z codes. Like the Z codes are not or they are? I would say that they would be HCC. Okay. They're not actually. They're not. Okay. No. So that's okay though. And I agree. I think these are part of the, it'll be interesting to see what happens because a lot of social determinants of health, we have Z codes now, you know, which aren't right now. So again, I think there's a lot of opportunity with Z codes for other reasons, but not HCCs. Okay, cool. Thank you. Yeah, that's okay though. Any other guesses on what might be HCC diagnosis codes for this patient example? So I think dysphagia following CVA, chronic systolic congestive heart failure, pressure ulcer stage four, major, no, that one's not. You're right. Major depressive, depression unspecified would not be, but major depressive disorder is. And that's it. Yeah, perfect. Exactly. Well, and dementia, I'm sorry. So dementia and Alzheimer's is an HCC. There's kind of a weighting that goes on. So it's not an HCC twice. It's just the one, but you are perfect on everything else you said. The following CVA complication, the chronic congestive heart failure, and the pressure ulcers, as well as the major depressive disorder, all HCCs. Dr. Cheng, were you going to add something here? Yeah, I was thinking about our audience. I'm board certified in hospice and pilot medicine as well. And I used to be the medical director for one of the hospice agencies here in town. As I'm thinking here and looking at the HCC presentation, I'm thinking, you know, how can I, if I was running the hospice agency or palliative agency, you know, I'm trying to branch into home-based primary care. What's one thing, what's one, maybe a mindset I have to change to make this work? I think in hospice and palliative medicine, hospice and palliative medicine, we're so, we're, we're not so, we're often focused on symptom management. You're short of breath, you're constipated, your skin is brittle or fragile, I should say. And we manage the shortness of breath with medication and so on. I think to go, if I was doing this kind of new, to go from palliative to primary, I think I'm going to need to ask my providers not only to think about the symptoms, but what's the cause underneath? And that's where it's going to bring me to the ACC codes. I mentioned yesterday, you know, unspecified COPD, they're short of breath. Well, you can get a lot more points if you diagnosed severe COPD or chronic respiratory failure. So taking that condition that you're treating, then looking at a deeper level as to the diagnosis or diagnoses that could be causing the patient's symptom, that may help me train my mind into thinking about ACC coding. Fragile skin. a lot of our patients are on chronic steroid therapy for, you named it, illness, right? So immunosuppression due to chronic corticosteroid therapy is an ACC code. So again, just think about the symptoms, what's underneath that that's causing the symptoms, and then think about the diagnoses. And hopefully that'll help you build better regarding to ACC coding. Yeah, thank you, Paul. I really love how you laid that out, because I think it's really important. And this is, I know someone mentioned yesterday, they're in a change management role in their organization. This is going to be change management for any providers, but especially for hospice and palliative care. Because, you know, yes, you're treating the symptoms, you're going to treat the symptoms, you can document that on your note. But what you need to code, Dr. Chang says, is, is there a confirmed chronic condition that's causing that symptom? As you know, this used to be less important. But as we're moving into value based care, and this is now getting tied into how practices are being paid, or how their patients overall severity of illness is being looked at. That's why this is super important. So it is a little bit of a mindset shift. And I mean, I'll be devil's advocate. And I know this is a very unpopular opinion. I always feel for my hospice and palliative care practices when I used to work with them. And I'm like, well, if we're thinking about from an ICD-10 guidelines perspective, this is not new. We have always told in the outpatient setting, you have to code the confirmed chronic condition and not the symptom when we're talking about diagnosis coding. So it is but it is a mindset shift, especially for palliative care. So what you should be coding what your those diagnoses that you're associating with your visits, even if you're still just doing palliative care, and you're not in primary care, should still be the confirmed condition that you were consulted and brought in for that's causing the patient's pain that's causing the patient's symptom. And again, as we're trying to all transform to value based care, this is where we really have to kind of start strategic planning on okay, how do we change that mindset? How do we help our providers understand that, you know, we're not just trying to this is not about gaming the system. This is not this is only doing what's appropriate, what's compliant, what's accurate for your patients, because it really is saying, hey, I have really sick patients, this is how sick they are. And this is why they need more resources, or I need more resources to take care of them. Yeah, one more comment as we're thinking about this mindset shift. One thing, and I don't know what EHR you use, you know, with our system, when you put in a diagnosis, it will pull up a list of potential diagnosis related to what you're looking for, like COPD or something, you'll put down a list. And on the list, some will have ACC label next to it. That can help you as you are coding and documenting and whatnot. And Brianna is going to talk about the meat thing again later on in her presentation. But yes, you know, EHR is a friend or foe thing. I, you know, use this as a friend this time, right? Talk to your vendor, can you build that into your EHR? So some of the ACC diagnoses, you don't have to go to another, you know, we're all sick and tired of, you know, going to different pages. Can it be built into your EHR so that your providers when they type in something, you'll pull down the list and they can appropriately code? Tasha, you have a question? Yeah, it just, as you guys are talking about this and talking about the mind shift, it kind of seems like a big part of the mind shift is from fee for service where we're incentivized and we're paid for interventions, right? Or lab tests or that type of thing. This is really incentivizing incentivizing and paying for what's actually going on with the person behind the scenes and the diagnoses and the, you know, the disease condition. Is that kind of? Yeah, I think you're very close. I think you hit the nerve of what we've been talking about for the last two days. You know, Dr. Siri talked about this change from fee for service. So under fee for service, you know, I can code depression unspecified, COPD unspecified. It's about volume. I get paid not because how sick they are. If I see 10 relatively healthy patients to 10 relatively sick patients, it's, you know, it's about the volume. So the mindset is not from a clinical side. I'm asking you to think about the diagnosis from the billing operation side. I need you to get away. I need all of us to get away from this volume, volume, volume thing, but tell the story of how sick your patients are because the financial engine is flipping is no longer going to be paid volume alone. And Medicare has made that clear is going to be tied to some value outcome in the future. So it's no longer just see more patients. Like I said yesterday, who needs me today and why? And because of their complexity, their sickness and so on. So tell the story as Brianna said, your payer has no idea what your patients are like, right? And use your coding to tell the story of how sick they are so that they will understand that it takes a lot of effort, a lot of money, a lot of manpower to take care of your patients. One more quick example here in terms of getting a different payment to help sustain a practice. I actually, you know, I work for Northwestern. I actually pulled a number of in-basket messages for me. I have a panel of about 250 patients. Okay. And I had them pull up a panel of a very busy family practice practice doc that has about 2,200 patients. Now just keep that in mind, 250, or let's just say 200, 200, 2,000. All right. The amount, the number of in-basket messages to me and to him are the same. His practice is 10 times bigger than mine. We get the same number of in-basket messages. And guess what? If you break that down, it's not refills, it's not MyChart messages, it's phone calls. So if you go, what am I trying to say? Build your visits right so you can get the reimbursement that you need to operate your practice. Under fee-for-service, you know, I can't get the money to hire the social worker. But if you're getting paid PMPM or some other APM models, you can have more, if you want to call it upfront cash, that you can hire a part-time social worker or pharmacist to help with these calls, to help with your management. These terribly complex patients, it was so eye-opening for me that, and I compared the in-basket messages, that my 200 patients and his 2,000 patients are the same. Yeah, I think that's a really good point. We can go to the next slide to continue this conversation. But I do want to call out too, yes, we're saying this matters a lot more in value-based care. This still matters in fee-for-service. It matters a little less if that's not how you're getting paid. But you working with Medicare Advantage plans, I mean, you can't be in this country and caring for Medicare patients without having to deal a little bit with Medicare Advantage. So it matters very much to them. A high HCC score, a very sick, a very complex patient on average is considered 2.0 or above, right? So that's what we expect home-based palliative, home-based primary care patients to be at. This was from primary care first, just showing the different risks, cares. And again, they're taking, the other thing that's hard about this is they're taking the average of a population, right? A risk score, when we're talking about it being a methodology, is not an individual patient. It's the average of your population. So I don't want anyone kind of taking away from this talk that it doesn't matter at all in fee-for-service. It just matters more in value-based, and that's where we're all going. So that's kind of why we're using it for as an example. But even for your Medicare Advantage plans, again, like Dr. Siri talked about yesterday, tell them you want to, you know, I take care of patients with an average HCC score of 2.0 or above, and these are the outcomes that I have. This is how I'm controlling their costs. This is how I'm reducing readmissions. Those are, like, talking points, whether you're in value-based care or not. And we can go to the next slide. So trying to give you all some examples. Hopefully, like Dr. Chang said, your EMRs have really been optimized, but this is kind of where it all matters when we talk about the level of specificity in your coding. Like I said, depression alone, if you said depression unspecified rather than, say, major depressive disorder, no HCC for depression unspecified. Yes, HCC for major depressive disorder. COPD is an HCC, right? But like Dr. Chang started talking about yesterday, is your COPD patient also in respiratory failure? Do they have, you know, have toxemia or hypercapnia, all of those things more complex than it alone? So use these slides as examples to go back to, but this is where we can really kind of take that level of specificity to the next level and help our providers understand why this matters because, again, we're telling them how sick our patients are, and we just have to stop those bad habits of using those unspecified diagnosis codes or just clicking the first thing that comes up on the problem list. This is where these annual wellness visits or certain types of visits, or use your staff, don't put this all on your providers, to update problem list and favorite list for them with more specific diagnosis codes is going to be really important. But Paul, any comments on the specific examples here? Yeah, keep a clean problem list and put some of these complex diagnosis there, so it will be a reminder for you as you are taking care of the patient. And, you know, we're going to talk about multi-complexity next, but you all know, like, what's the third one here, hypertensive heart, CKD, heart failure, how many of our patients got that? It's like almost everybody, right? So keep that in mind. Again, it's not about gaming the system, as Brianna said, it's about telling the story. And education, we have somebody actually scheduled somebody from CDI from Northwestern to come and give us an in-service on ACC coding in like a week or two. All right, so we are still under fee-for-service for the most part, but we are pivoting and I'm trying to get myself and all of my providers thinking and optimizing and doing our best to get the ACC scores higher. So education is key. Also, you can just, your providers can share, like somebody found something like functional quadriplegia is an ACC, carries ACC weight. Hey, you know, I found this and then your providers can share with one another. So it doesn't have to be like formal education, but it could be just each other helping one another. And the final thing about your EHR is, do you have a dashboard? You know, I have a dashboard on my EHR here, under population health, I can click here and look at my ACC score. It's generated every month. It's updated every month. So I can see my curves starting, as Brianna said, you know, January is nothing. And then now it's September. So I should see a rise in my ACC score as I'm accumulating patients and seeing patients. So having that dashboard and being able to find out, you know, which patients have low ACC scores and potentially what gaps, you know, in my dashboard, I can see the actual ACC and ACC gaps. And how can I maybe close the gap for those patients? So a dashboard, education, and optimizing your EHR. Those are just some of my comments. Thanks, Paul. And we can go to the next slide. So also, again, when we're talking about compliance and still making sure, there's a couple most miscommon, where you're actually incorrectly inflating the risk score, usually unintentionally. So a CVA, an active CVA is only coded when the patient's in that acute phase of care for their CVA. Same with MIs. It has, from an ICD-10 diagnosis code, you can only code an active MI for four weeks old or less. So you may be seeing patients during that acute phase or that active MI, but usually, especially when we're thinking home-based primary care, the example that we had with that patient where you're coding the dysphagia following the CVA, what is the residual effect, if you will, of that CVA? Because then it becomes that Z code. Then it becomes that history of, or hemiplegia or hemiparesis following a CVA. That's an HCC. So those are the things that we're looking, just a couple to, I like to call these out just because they're usually common mistakes that I'll find when I'm reviewing that documentation for your accuracy of HCCs. And there's other things outside of your EMR. There's all sorts of apps. Again, just use your resources. ICD10data.com, if you're not sure of the appropriate clinical guidelines for a condition, can be super helpful. Again, not expecting providers to spend time doing this, but for the practice staff that's helping to train and champion that change management, they can be helpful tools as we're developing resources for our teams, talking about it in staff meetings, so on and so forth. Next slide. I think we really talked about this, too. Again, you do want to be careful, especially if you're being told to code something by a payer or something that's probably not appropriate. You care about quality. You care about cost savings. You care about making sure that your patient is accurately being reflected at how sick they are, but you do need to prove it through your documentation. So if you're coding the diagnosis, I need to see it in your assessment and plan. It needs to be accurately represented. Again, you have 12 months, 12 calendar months to capture all of these patients' HCC diagnosis codes. So make it a process. Bad habit to avoid. Again, not just prioritize your assessment and plan and choose the diagnosis codes that are top of mind and that the patient is really dealing with at each visit. A standard CMS 1500 form, typically you can get about 12 diagnosis codes that actually hit as billable, supportable diagnoses, sometimes more. So that's when we want to tell our providers, too, to prioritize your patient's care and really choose the diagnosis codes that you're caring for that patient for. And that kind of gets into the meat. So we talked a little bit about this yesterday, but again, if it wasn't evaluated or considered during that specific encounter, then I don't want to see it coded. Don't let the meat, meat is a best practice. Don't let it scare you. Maybe there is a specialist involved in treating the patient's cancer or Parkinson's or whatever the case may be, but you're still considering and co-managing or have a part to consider that diagnosis in your care of the patient, then it's completely appropriate for you to still code that diagnosis as long as your documentation reflects that. So we talked about yesterday, what's the status of that condition? What are you doing about it? What are you counseling or educating the patient on? How are you considering that disease in your care of the patient? Focus on that rather than saying managed by oncology or managed by neurology. That's what we want to focus on just to kind of validate all of the diagnoses that we're coding. If we go to the next slide, I think we talked about this a little bit more. We can go more. Again, just kind of giving you those tips, those words. One more slide. Sorry, I'm trying to get here again. So again, making sure that we're trying to avoid unspecific documentation that really doesn't reflect where they're at in their illness, what specifically you're doing for it. Oh, I was skipping ahead. And then I'll come back to how there is a compliance kind of caveat to all of this where Medicare is auditing their Medicare Advantage plans and trying to validate all of these HCC diagnosis codes. So that's why it's mattered because your face-to-face progress notes, this is what they're looking for. At the end of the year, they do annual what's called RADV audits where they're checking all of the HCC diagnosis codes and making sure that their face-to-face progress notes that's showing some assessment, some actual consideration of the patient's diagnosis codes. Next slide. Again, these are just more for reference, but another thing that, from a coding perspective, ICD-10 guidelines, important to keep in mind is when we see the word with, that can represent a causal relationship. So, if the patient has, you say the patient has hypertension with heart disease, well, there's a combination code that would be a higher HCC than not documenting that relationship. So, just another little tip, trick, something for you to keep in mind. If you're saying the patient, if you're using one of those diagnosis codes, your documentation just needs to represent that relationship, which you can simply do by saying with, if those two things are really related. Paul, any of your favorites here, things not to miss, kind of how you capture some of these? Oh, artificial openings, colostomy, G-tube, tracheostomy, tube. We do procedures at home. Well, I should say some of us do procedures at home, like this past week or two weeks ago, changing a G-tube. Again, I'm doing something and I should be, not reimbursed again, it should be noted that I'm taking care of a sick patient who can't eat by mouth, who's got a breathing tube or a G-tube. So, that's one of my favorites. Functional quadriplegia, we talked about that, thrombocytopenia, and then pressure ulcers, atrial fibrillation. And also, there is another code that hypercoagulability or hypercoagulable state due to atrial fibrillation, that also is an ACC score, all right? So, keep that in mind as well. Stages of CKD, again, we'll talk about that in the next session. So, those are just common things to keep in mind because you're going to be seeing them over and over again, depression, heart problems, breathing problems, kidney problems, diabetes problem, and so forth. So, those are some of my favorites. And as Brianna said, there's so many more. So, educate. We have more examples too in the next couple of slides for, again, just trying to make kind of make the connection of which chronic diseases carry an HCC weight. Like Paul said, important thing to keep in mind from a provider perspective, when the patient has a pressure ulcer, what stage is it? When the patient has CKD, what stage is it? All of those things are kind of really painting that full picture. Even if you're not doing procedures like Paul said, if you're taking care of the trachea or evaluating the trachea gastrostomy site, those are probably the only two Z codes, Kim, to your point, that are HCCs. So, just trying to kind of call out some things. Morbid obesity, right? Obesity unspecified would not be, but if the patient has morbid obesity or their malnutrition, you know, mild protein calorie malnutrition, things like that. We can go one more too, just trying to get you familiar with some of these common diagnosis codes that, you know, that side effect following the CBA or that complication, like we mentioned. Paul, any thoughts on these? Oops, sorry, go back one, on these specific examples? Yeah, I don't have any other. Yeah, we already said about coding to the highest specificity that you can. And again, asking your EHR, your electronic health records to help you so that, you know, I'm getting older, I can't remember all this stuff. It's just impossible. So, having your EHR be your friend here and give you a little boost, I think will be hugely beneficial. All right, thanks, Paul. Next slide. So, this is, again, just for you to know about, it's more, these RADV, which stands for Risk Adjustment Data Validation Audits, is something that Medicare and OIG do on an annual basis to make sure that they're appropriately paying the Medicare Advantage plans. Again, the point here on what matters for our practices is just you have to be supporting the ICD-10 diagnosis codes that you are reporting. So, again, we're always fostering that culture of compliance. You know, we're not trying to inflate risk scores. We're only really coding what's appropriate. Why that meat is important and why we've brought that up so many times, though, is because it's dependent on your face-to-face progress notes. So, it could be completely appropriate. But if your documentation really isn't supporting that patient's, you know, your evaluation or your consideration of those diagnoses, then that's going to be a problem during these RADV audits. And it's not, it's no fun to be on your partner's bad side, right? We want our payers and our value-based payment models to understand that we're doing our part through documentation to support these diagnosis codes. So, we've talked about some of these. Paul has really been a, you know, I think you're a great example of how you're a champion in your practice and how, you know, this is a continuous improvement effort. This is a continuous focus that you're getting better about and you're kind of encouraging your team to do. I've put together kind of a list for you of implementation considerations. You know, we've talked about some of these. I'll elaborate on a couple. But Paul, you want to talk about just kind of reflecting on your journey from when HCC was brand new to your practice. You know, how did you kind of continue to evolve and get where you are now and then continue to focus on it? So, many of you are leaders in your practice. And I think the leadership has to set the tone and also give your team the reasons behind why we're doing this. So, I would say that if you're not, like HCC is relatively new to you, go read about it. If you have questions at the end of our session here, you know, raise your hands. We'll be happy to answer them. So, get acquainted with HCC. Get comfortable with HCC as leaders. And then share that with your team as to, you know, why we're doing this. It's not to burden you with more documentation, you know, just like good grief. You want me to do something else. But explain to them why we're doing this. You can start one at the 30,000-foot level, as we say, right? You know, the landscape is changing. Fee-for-service used to be this, and now we're going to that. And if we want to keep the lights on, hey, if we want to get more help to help you take care of patients, to get a social worker that we're desperately in need, this is where it comes to play here. So, understand yourself about HCC, the importance of it, and then being able to articulate that to your team on the importance of this and answer their questions. And then I think, you know, work with vendors and work with your coaches to continually improve your scoring so that we can always do better and get the reimbursement that you need. You know, Brianna talked about the PACE program. PACE program, I mean, they are so focused on HCC scoring because their reimbursement is so intimately tied to HCC coding. So, I guess I'll just summarize by saying, you know, get knowledge, articulate your vision, work with your vendor on EHR, and get some coaching periodically to improve your scores. I know one practice that turned, they had like a, you know, there are certain months of the year that they focus on annual wellness visits, which is really when they encourage their providers to code all of the conditions that the patient has, right, and document a plan for that. And they turned it into a game. It took a little bit of manual work from, I'm not sure if it was the practice manager or the coding staff that was doing it, but they kind of said, okay, who can capture, you know, the most HCCs or have the highest HCCs for their patients. And then they did, you know, prizes at the end of that week just to really get people thinking about it. There's systems and, you know, things that we can put in place. Again, this doesn't have to be all on the providers, medical assistants, students, like that wonderful point, Dr. Siri, take five charts, just five progress notes, and do a peer audit, and then get the team involved and review that at a staff meeting. That's a great example. I believe Dr. Siri did that in her practice. You know, think about how you can cross-train other team members to kind of help set things up for your providers, use the tools that you have, and then just do some internal auditing and monitoring. Again, small sample sizes. This could be an annual or biannual process, you know, trying to make sure you've captured codes for your patients towards the end of the year or maybe at the beginning of the year if you're doing annual wellness visits then. Think about creative ways that you can kind of make this fun for your team as you guys are all learning together. But just some best practices for you to take away. Just one more comment. My EH, again, I'm part of Northwestern, and my patients go to essentially, you know, Northwestern hospitals, so that their records, their tests, and their imaging and all of that, it's available to me in my EHR. For practices that are not connected intimately this way, I think it will be very important for you to get some of the records when your patients do get hospitalized, get some of those records from the hospital so that you can, again, put it on your problem list, such as atrial fibrillation or even like calcification of the aorta, okay, that has an ACC score. How many of our patients fall and get a CT of their head, and the CT invariably says what? Cerebral atrophy and small vessel disease. Those are all ACC-weighted conditions, okay? So get that EHR to be your, no, no, no, get the medical records so that you can have a true picture of how sick your patients are so that you can properly populate it in your EHR so that their conditions can be captured. Thanks, Paul. I wanted to pause here for questions, comments or questions. I have a few more slides that I really just put in as a resource for you all, but before we get to that, happy to take any questions or comments from anyone. Hi, it's Janine Ellenwood with Snowline. Hi, Jan. I was wondering if, so we're working with a provider group that has an at-risk MA plan, and we're doing, offering PMP palliative care for their high-risk. Would we be able to talk with them about high HCC scores to be able to identify patients that would be high risk for readmission that we could help support? Would that be one way? Would they have that information? Yeah, absolutely. They should. That's a great point. So especially if you have like a larger organization that's at risk, whether it's an ACO or a partner organization, they should be able to provide this data to you. So believe me, you're preaching to the choir with some of the limitations with hospice EMRs. I know. That's why I'm trying to throw in as many other ways, but I think that's a great solution. Your partners, especially if they're at risk, they're getting some sort of reports on HCCs or their patients, so they should be able to kind of help you with some of that data, and you can use that then to your advantage. Dr. Siri, I saw you come off mute. Did you want to add something? Yeah. So I think that's a wonderful thing because what you can also tell them is that you can support them in validating the HCCs and the diagnosis. So they are constantly looking to revalidate their HCCs and the diagnoses. So as a partner, and that was one of the big things that we did for one of the Medicare Advantage plans that we worked with, we actually helped them enhance their HCC scoring because their doctors were really not doing it. So as a palliative care team, when I started writing my notes, when I did the IDT meeting, I would review the labs. I would add those diagnoses, whether they had CKD or whether they had chronic AFib or they had diastolic heart failure on echo or they had atherosclerotic heart disease. So just those kind of things that you can add and help them as well. So you become a great partner for them. So it is back and forth. I mean, they are sending you those patients because they have high HCC scores and high utilization, but they could also be just sending you those patients because they have high utilization, but they might not have a corresponding high HCC score. That would really be a big help for them because then they can get more money out of Medicare as a Medicare Advantage plan. Yeah. Yeah. Under value-based care, data is so important. Be concerned of getting into any relationship, payer or otherwise, if they don't allow you to see data. You're going to be driving in the dark with your headlights off. I'm just concerned that you're going to have a bad outcome if you have no access to data of any. Just look at what Aaron presented. It's all data points. Yeah. Enough said about that. That's great. Yeah. Melissa, if you can advance through to the slide 55. Like I said, I wasn't planning on going over these. Common chronic conditions. Diabetes. I did some of the work for you and just said heart failure. What type of heart failure? Is it acute on chronic? Is it acute or chronic? COPD? Is there an exacerbation? Do they have respiratory failure? Do they have other complications? I wanted to highlight a few resources for you, but, Janine, that was a wonderful point. Use your partners. Someone has data if you're at risk or working with those, so be creative on where you can get those kinds of reports for. Outside of your EMR, there's lots of options. This is the CMS Risk Adjustment website. I can actually put the link in the chat for you all, too, but it is on your slides. What you want to look for is where it says whatever current payment year it is, that final ICD-10 mappings. It's an Excel spreadsheet of every ICD-10 diagnosis that carries a risk adjustment weight. When I would do HCC auditing, I would use this to reference what diagnosis it is, calling out to the providers, which ones risk adjust, which ones they might have missed, or things like that, so that can be another resource for you. They also put a lot of other announcements and resources up here, so just another CMS resource for you to be aware of. If we go to the next slide, this is just a screenshot at the top of another resource we've given you in the HCCI Learning Hub, where we've put together kind of a grid of a lot of these example diagnosis grids, so you could use this in a staff meeting to kind of talk about it, why it matters. Wanted to give you all some tactical resources to take away from today. So, key takeaways. Again, remember, your patients are... Go ahead. Yes. Anna, I think... Did we not provide them the HCC course as part of their online bundle? I think we did. That's another... Oh, that's a great point. Yes. Thank you. ...to review some of this information, but that's part of their online course bundle, so sorry. No, thank you for that. I'm not as familiar with the package you put together, so that's great. So, I know you all, to Melissa's point, have some access to some online courses. I had just worked with HCCI to revamp the HCC course in 2022. I think you deal with Paul and I in some videos that we put together, but that could be a great thing to watch during a staff meeting. This is a process. It's continued learning, so assigning that to your team or watching it together during... I think it's only about a 30-minute online course during a staff meeting would be a great kind of next step from education. But your patients are reborn January 1st every year, so it's an annual process. You have to be specific. You have to code those ICD-10 diagnosis codes to the highest level of specificity, support it through your documentation, and to Jeanine's point, use your partners, do some internal monitoring. I love what Dr. Seery said. Small sample size, just five notes of peer auditing. We talked about kind of how that can boost team collaboration yesterday. But, yeah. Any other closing thoughts, Paul, from you? Yeah. If people have questions, you know, Brianna and I, we can talk all day about this, but that will be really boring. So we would love to entertain questions if you have them. All right, if there are no questions, let's move on to the next slide. Thank you, Brianna. Before I start here, I am going to put some links. Let me just type them in. This is a good opportunity for everybody to do a mandatory stretch break. Yeah, I'm going to be referring to these. It doesn't look like they're coming across as links, Paul. Oh, they're not links, sorry. My bad, I misspoke. Yeah, I think that's, yep. Yep, and I'll be referring to those later on. So almost lunchtime. Yeah, there was a lot of information this morning. I hope you've found them to be helpful to you. And we're going to talk about taking care of our multi-complex patients at home. Next slide, please. I don't know. So I was thinking about, you know, what did you do to recharge last night after a long day listening to us talk and so on? Something I did with my daughter was I was looking up some clean dad jokes, okay? And maybe I'll just share one with you before we get into the really serious stuff here. What's one joke? Okay, why did the tomato blush? Because he accidentally saw the salad dressing. Okay, I will stick to my day job and being a doctor and a consultant here. So we're going to talk about the challenges of treating homebound patients with multiple diseases. We're going to talk about a management model and taking care of them. And we're going to talk about probably top four conditions that we encounter at home, diabetes, CHF, CKD, COPD. Now there are two others that I want to highlight here for a minute. Dr. Siri's presentation, I believe yesterday, talked about, you know, the cost of care and so on. And one of the conditions, if you will, that's associated with a higher cost of care was dementia. And HCCI has a dementia module. Melissa, I think it's like maybe an hour long, perhaps. There is a lot of information in that dementia module. It talks about treatment, diagnosis, non-pharmacologic intervention and pharmacologic interventions. It's a great program. I encourage you to take a look at that when you have a moment. And also in development to be released, and you can correct me if I'm wrong, Melissa, I think in October, we're going to have a module on management of psychiatric illnesses in homebound patients. How relevant is that, right? So reach, well, check back with us in October and go find the dementia module that can help you get more confident. Remember, we talked about resilience yesterday. One of the elements of resilience as I see it is just being confident in your art, in your practice. Next slide, please. Sarah's going to put that link in the chat for the dementia course. Next slide. So what are the challenges in, you know, going, let's just say, we're going away from hospice and palliative treating symptoms, and now we're taking on home-based primary care, right? What are the challenges? Because, well, our patients have multiple chronic conditions and it's not uncommon to have as many as 10 or more. They are taking multiple medications. You know, I'm not an academic, but we did publish a study looking at the number of medications that my patients take. And the average number was 17. That, you know, that's, it boggles my mind. You know, how do you keep track of 17 pills? How do I manage side effects or drug interactions, right? So they take a lot of medications. They're at risk for going back to the hospital. They're high utilizers. We saw the graph, you know, top 5% uses 50% of Medicare dollars, and the top 1%, we're kind of even going that direction, use about 20% of Medicare dollars, okay? And they not only have one condition, they have multiple conditions that contributes to their functional and cognitive impairment. And Brianna talked about, I like to look at the care at home as always a dyad. It's always the patient and the caregiver. We need to work with not only the patient and their complexity, but we also need to work with the caregivers and answer their questions about their medications and so on to help them take care of their loved ones. At home. Next slide, please. Yes, and you can put all the bubbles on. So when the residents come and rotate with us from Northwestern, one of the comments often is, how do you take care of these patients? They are so complex. Or how do I approach a patient when they're so sick and there's so many issues, right? So I tell them about the four M's, and we're gonna go through them quickly here, or briefly here, I should say, and you can see where the four M's came from. And then the fifth M is multi-complexity. You can stay here, that's fine. No, that's fine, you can go to the next slide. So the first M is what matters. And this is gonna drive a lot of your clinical decisions, your care plans, and your recommendations, right? Understanding your health goals and preferences. Is it ICU? Is it hospital? Is it find out what that spot on the breast is? Or is it more comfort-focused, less intense intervention? And if that spot on the breast is cancerous, so be it. All right? So the goals are gonna drive what you recommend to your patients and families. Applying prognostication in decision-making in the context of what are the burdens and risks and what impacts it may have on your quality of life. Now, we often think about like chemotherapy, diarrhea, and your hair falling out, and those are some of the burdens and so on. And obviously they do exist, but putting into the context of the four things that we talked about here, heart failure, diabetes, et cetera. What about the frequency of blood testing for your diabetes? What about the frequency of blood testing as I'm tinkering with your diuretics for your heart failure? Those are all burden. Or we talk about ACC scores, about dysphagia, and do they want pureed food? I have a patient who told me, I'm not gonna use thickened liquids. I know I'm at aspiration risk. I'm not gonna, I want to drink coffee the way God intended it, right? So that was his goal. And my care plan is gonna be, you can drink your coffee. Coordinating advanced care planning and communication with this clearly. You know, this is such an important part and it's a quality measure, depending on what measure you're following in terms of the quality, showing quality to your payers or your health system or whatnot. It is very important to have that discussion and don't forget you can coach with that, right? We talked about that yesterday. Making sure that the care plan is clearly documented in your EHR, that relevant people are aware of what the decision is regarding resuscitation and so on. I have this illustration is what I call the angry relative from Arizona syndrome, right? You know, everything's planned. We, you know, mom's declining. We talk about this. We talk about, you know, getting hospice and all that. And then you get a phone or the office gets a phone call from the angry person in Arizona, says, how dare you? I'm gonna sue you. I'll sue you in court and it's all heated, right? We don't want, I don't want that. And you don't want that. So make sure that it's clearly communicated with those who need, who needs to know. And of course, updating the care plan when you need to, when their health condition changes. For example, I have a patient whose power of attorney was the wife was really healthy and he has dementia and she passed away suddenly. And now the family, we need to reestablish a POA with the family because the wife really took care of patient for everything. Okay, next slide, please. Mentation, you know, COVID has been so hard for our seniors, right? Thinking back, it's been two plus years. Remember the lockdowns, the isolations in the room, can't come out if you're in assisted living, food was delivered to you. And you can, you can look up on the internet how awful that was for our seniors. So mental activities is so important. Help maintain, help do what you can. Talk with the family about maintaining cognitive wellbeing. It could be games that they do or senior center a couple of times a week, not only to give the caregiver some time for themselves, but also for social interaction and games. Identify and address what may be the cause of the cognitive impairment. You know, it could be me. It could be inadvertently that I am giving this patient too much of XYZ medication, or maybe I should have checked or whatever, a thyroid level or something. So keep in mind, it might not be just because they're aging, it could be. Caregiver, I already said enough about that. If they fall down figuratively, then our patients, they're not gonna get the care. So don't forget your caregivers. Protect patient from delirium. Again, I think one of the best way to do that is to keep them out of the hospital. I think we all experienced that. Hospital's great. I mean, obviously I work for the health system. I'm not bad mouthing them, but we know what happens when we put a 90-year-old patient with dementia in the hospital. Yep. And then don't forget to treat mood disorder, depression, anxiety. Again, just another plug to be on the lookout for our module that's coming in October that will help you deal with some of these challenges. Next slide, please. Mobility, maintain the ability to walk, minimize their risk of falling, right? We don't want them end up in a hospital with a broken this or that. Involve your team. I'm not a physical therapist, I'm not an occupational therapist, but they can provide such insight into what you can do to help this patient from falling down or to improve their ability to do their ADLs or IADLs. Okay, I only know so much, and I've often said I'm just a doctor, which is true. And I don't know all the other skills and insights that the other disciplines can bring. So don't forget to involve a team. And next slide, please. And medication. I already said, you know, 17 medications, you know, wow, that's just a lot. Realigning the medications with a person's individual needs and goals of care, right? If the goals, if one of the goal is to reduce polypharmacy, maybe the statin is no longer necessary, right? I go through every single one of your medications. This is what I teach the residents here. We all do, here are the four steps. We all do medication reconciliation, we all do that. The next step I want to do is I tell the residents, do medication justification. Is there a reason for the patient to be on this? Okay, I pick on PPIs all the time. You know our patients, they're all on PPIs. PPIs, the joke is an indication that the patient was hospitalized, okay? So medication reconciliation, justification, optimization. We'll talk about that later. Has it been optimized for kidney function, liver function, drug interactions? It's going to be key if you take on primary care, no longer we're just dealing with symptom management medications. And now we're talking about amiodarone. What are the side effects? Even Keflex, Cefalexin or Bactrim antibiotic, they all have to be renally dosed, right? So keep all of those in mind. So reconciliation, justification, optimization. The last one is demonstration. And we'll talk about that in the COPD section as well here. Being at the home, you get the chance to see how they use their inhaler, their insulin, even how do they take their medication? Show me you understand how you do your pills. Yeah, the others are pretty much talked about a couple of things. There's the I think many of us know about the various criteria for potentially inappropriate drugs for elderly, but don't forget the also the start stop, you can Google start stop medication, potentially, we should start it for patients with certain diseases. And I'll talk about that a little bit. Next slide please. So we got the big four, four m's and now we have to put it in a manageable form. Right, helping older patients manage their multiple multiple conditions. Choose a therapy that optimizes benefit and minimizes harm enhances the function and the quality of life that's consistent with their goals of care. Get partners in to support. We talked about getting like a physical therapist, or there's like a psychiatrist or psychotherapist that's available to you either by face to face visit or by tele. I think that will be a wonderful option for you. Incorporate different philosophy of care by that I mean, you know, is this more longevity is that what we're going for here, or is the philosophy now pivoting more it's more comfort measures and work with your specialist. And I think, well anyways work with your specialists. We have another talk separate talk on how to integrate interact with specialists when your home, primary care providers, get their input, because your families, your patients may want to know you know what is Dr. Smith think about that you know how do you interface with these specialists. I think it's going to be important as well. Next slide please. So this is the model just to keep them. Keep in mind because it's a moving piece. It's not like, Oh, I give you this. I'm done. You know I'll see you in three months. You know it's never like that. We process we plan. We execute. And we check on the patient, a week, a month later, and then we adjust. And then we do the whole cycle over again. So probably one of the key components of this multi complexity here is we're teaching the learners, students and others on in terms of having a framework to juggle all these all these pieces that they're facing. Next slide please. So, the plan is, again, you know, the patient's goals of care. Symptoms should be addressed. What are the impacts on the mobility and safety and preventative care and other obstacles that that you may be facing. So that's one of the plan part in terms of as you're thinking about the approach for your patient. Next slide please. I don't hate to be jumping back and forth, but I'll just use CHF as an example here. Not all shortness of breath is CHF exacerbation. Right. Think about other potential diagnosis which which we'll talk about in a little bit. And think about what testing may be needed. Can it be done at home. Some may be. Some may not be able to be done at home, right and you need that goals of care conversation with the patient and family. Don't forget mental illness. Don't forget their living conditions. I do what I call the walkthrough on a new patient visit. Yes, as in real estate, the walkthrough. Right. So take me to the kitchen. Take me to the bedroom. Take me to the bathroom. How does he get from point A to point B. How does he get out of the house if we needed to get a CAT scan or whatever. Assess the living conditions. Have a better understanding of what the patients are facing and then you can better intervene here. And then other contributing factors, other psychosocial, the social determinants of health that might be impacting the plan. For example, if you want to do a want to do a televisit with a patient as a follow up potentially, but they have no tablet, no high speed Internet and so on. You may have to intervene in another way. Right. You may. Television may not be an option. You may have have to come through the door again. That's just an example. Next slide, please. The do is. Think about what lifestyle modification is. And I pause here. What is reasonable? Right. Should I tell a 95 year old not to eat steak and ice cream? Right. So think about, again, it goes back to the goal and you recommend based on the goal. So you could talk about lifestyle modification if it's appropriate with the goals of care. Again, the treatment need to be aligned with that goal. If you're going to intervene in a certain way, we're going to talk about that in the four diseases here. Next slide, please. So I pause here. Talk about the potential why you're doing this, the potential benefits. What are some of the side effects? Always, always, always think about deprescribing. That will give you some deep prescribing protocols of common medications like antipsychotics, proton pump inhibitors. So I encourage you to go to that Web site and give you some guidance on the prescribing. As you do the walkthrough, think about what DME they may need. Maybe a shower bench. Maybe it's a lift chair. You get the idea. And then don't forget getting other team members involved in taking care of your patients. Next slide, please. Check and adjust. We talked about RPM. It is a great way for you to sort of be there and be with your patients, even though when you're not. And again, as Dr. Siri and Brianna talked about, now we are able to get paid for RPM. If things are not going well, if the diagnosis is uncertain, rethink about your intervention, your diagnosis and your intervention. Always be on the lookout for adverse reaction related to a medication. And as I said earlier, the one of the beauty of being at home is that you get to see you get to you get to bet you have a better sense of whether your patients are taking their medications appropriately or not. And finally, periodically talk about periodically talk about the goals of care, especially when they're home from, say, a hospital stay or nursing home stay or a death of a loved one or something. Those are those are some opportunities for us as providers to go in and say, hey, how do you feel after this hospital stay? Was it rough? Yeah. You know, have have your goals changed at all? Next slide, please. I'm going to stop. And any questions so far before I get into some of the specifics? OK. So one of the app that I use is the on my phone, that is it is the ADA standard of care. I encourage you when you have time to download that app and take a look at some of the capabilities, some of the point of care advice it can provide you when you're having that conversation with with a patient and their loved one. For example, what's a reasonable A1C goal? So as we talk about diabetes and thinking about the kind of patients that we take care of, right, 80 plus multi complexity, multiple comorbidities, life expectancy, probably moderate or perhaps short. We need to talk about the blood sugar goals and the frequency of sugar testing. Review their medication and think about any barriers to them taking the medications correctly. And I showed you yet or I talked about yesterday how the family didn't know how to open that bottle of the pills. They had to burn a hole through the side of the pill bottle. It's just like, wow, that's a barrier that I have not seen before. Identification with diet, if consistent with goals of care. Exercise is tolerated, again, if consistent with goals of care. If they're able to follow up with a specialist, if they want to follow up with a specialist for their heart disease, for their nephropathy, you can encourage them to do so. Otherwise you may, many times we become, we take on the roles of being specialists because we are often the only providers that go into the patient's home. So by default, you become an endocrinologist, a cardiologist, a pulmonologist, and a nephrologist, okay? And monitor the hemoglobin A1C, again, if it's appropriate. Next slide, please. Obviously in an hour or even 30 minutes, I cannot go into the details of diabetes management or heart failure or COPD, right? What I hope to do is give you like a high level of working knowledge, especially for those of you who might be, who might have to relearn some of this as you go out of the palliative hospice mindset into more of a primary care provider mindset, right? So what are some of the common medications that we use for type 2 diabetes? Metformin is still probably the king. It's got a proven record. It works great in terms of reducing your A1C and it's inexpensive. So that's often, it still remains as the first line therapy for many of my diabetes, just, yeah. I think there are a couple of caveats with metformin. There's the GI side effects you need to be aware of. Long-term metformin use can lower your B12. Keep that in mind. And the dosing is GFR based, not creatinine clearance based. Okay. Keep that in mind as well. There's an app. Where's my phone? If you want to do a creatinine clearance, this app that I use often to help me with not only prognostication, Dr. Siri talked about University of San Francisco having their program, their software, but I use MD-Calc a lot for my calculation of creatinine clearance, but also for other prognostication tool, right? Sulfonylurea, we can, we still use, it's cheap. It's an add-on therapy to metformin. One of the main concern with using sulfonylureas is hypoglycemia in our older patients. DPP-4 inhibitors, I don't use that as much because there are new and better medications than DPP-4s in lowering blood sugar and helping our patients in other ways. And these newer drugs are GLP-1 agonists. They're injectables. Victoza, that's one brand name of an injectable medication that we use that is very helpful either as monotherapy or add-on therapy to help manage diabetes. Or there is the oral version, it's called semaglutide. Brand name is Rubellsis. The side effects, GI upset, and there's been reports of severe gallbladder conditions related to that use. So just be aware of that. And there's also a black box warning related to its use, mainly with a history of thyroid disease or multiple endocrine neoplasia. So use your app as your friend to learn more about GLP-1s. SGLT2 has gained a lot of attention recently. Again, it's used either in monotherapy or other medications in lowering glucose. But now there is data that demonstrates that these SGLT2 inhibitors are very effective in managing heart failure, which I'll talk about later on, and also delaying the progression of CKD. So again, the medications could be a little costly depending on the patient's insurance and coverage and so on. So just keep these two categories of medications in mind as you're thinking about management of diabetic patients with multi-complexity. Thiazolidine diomes, I don't use that very often. Actos is a brand name. Pyoglitazone, I think, is a generic name for that. It can be add-on or a combination. It could be a monotherapy or add-on therapy to metformin or your SUs. But one of the main downside to thiazolidine diomes is leg swelling and fluid retention. And dealing with patients, you get the idea. I don't want to go there. And then get comfortable with different kinds of insulin therapy. There is the long-acting, and then there is the short-acting, your Humalog or your Novolog, and then your long-acting is your Basaglar or Lantus. Get comfortable and understand the kinetics related to how they're used. Any Star Wars fans? I don't know. I'm a big Star Wars fan. Depending on the response, I may or may not share with you the Star Wars joke. Maybe not. Alright, moving on to congestive heart failure. Go for it. Alright, so for those Star Wars fans out there, you know Yoda. Yoda answers in kind of like a rhyme, right? There's no try, there's only do, or something like that, right? That's Yoda. So the joke goes like this. What did Yoda say when he finally saw himself in 4K? He said, HDMI. Okay, we'll move on to congestive heart failure. HDMI is the kind of cable for those. Alright, for the congestive heart failure, go to the two apps that I showed you. There's the Guideline app from the ACC, and also the Treat HF app from the ACC as well. So we all know about, get familiar with some of the new lingo. Not that it's going to change our management a whole lot. We all know about HFREF, HFPEF, and now there's the HFMREF and the HFNPEF. Get comfortable with some of the language. This guideline, I think, was released by the ACC this past April, so it's relatively new. So get acquainted with the new terminology. A general consideration, salt and fluid restriction, again, if it's consistent with the patient's goals of care, if they want to stop smoking, encourage them to do so. It's so important to get them weighed daily if at all possible. Sometimes it's not. Some of our patients really cannot stand and balance themselves to be weighed daily. But if it's possible, you know the talking points of three pounds a day, five pounds a week, you've got to call me. Medication compliance, we're going to keep thinking about that. Address barrier and so on. And have an emergency action plan. This applies not only for heart failure, but it's going to apply for your COPD and your diabetes and so on. The patient should know when to call you and what number to call you if they experience a change. Weight gain, leg swelling, shortness of breath, loss of appetite, blah, blah, blah. Okay. It is so important as we pivot into value-based care. If you're responsible for the total cost of care for your patient, if one of the measures, as Dr. Seery said yesterday, was stays at home. They need to know what to look for, what am I in danger, who do I call, and what to do. So whether you provide that on your after-visit summary sheet or in your refrigerator magnet or your welcome packet for your patient, they need to know how to get a hold of you when they're in trouble. Next slide, please. Again, a high-level overview. Many of us know that our patients are on furosemide. That's probably the classic loop diuretic. But if you're not getting traction with furosemide despite increasing the dose of furosemide, I would recommend you go to a different loop diuretic. Bumetanide or Bumex is one I often pivot to when I cannot get the decongestant, as they call it, or diuresis that I'm looking for with furosemide. There are a couple of reasons, including the kinetics, the longer-acting feature, if you will, of Bumetanide versus furosemide, and also in terms of bioavailability in the gut, when your gut is so congested with heart failure and so on, Bumetanide has an advantage over furosemide in terms of bioavailability. Keep that in mind. Bumetanide, just like we do with opioids, when something isn't working, when they're having opioid toxicity or whatnot, you rotate to a different opioid. I want you guys to keep that in mind. You maybe rotate to a different loop diuretic when you need to decongest the patient. Thiazide diuretic, the one that I use when I need a little bit more diuresis with my patient and I'm getting maxing out on some of my loop diuretics, I use metolazone. I usually generally do not use that on a daily basis, perhaps once a week or even PRN for weight gain. That's often used in combination with a loop diuretic. MRAs, spironolactone or epleranone, you can see the indication there with Hef-Pef, MREF, and Hef-Ref. ASIS-ARBs, and now with the new class of medication called ARNI, angiotensin receptor neprilicin inhibitor. The classic drug is Cucutrobalsartan or Entresto. I'm sure many of you heard about that. If they're able to afford or pay for this medication, it is the go-to drug in patients with low to normal EF. I think the study says it's 57% or less EF or those with Hef-Ref. So your ARNI agents, if they cannot afford that, then your ASIS-ARBs, which we all know. Hydralazine isosorbide, those patients who cannot tolerate other, if you want to call it more traditional therapy. And then your heart failure indicated beta blockers. In the U.S., the ones that we commonly use is metoprolol succinate and carbadolol, either the IR form or the CR form. Next slide, please. Switching gears to COPD, what are our goals? Reduce symptoms. We want to have them improve their ability to exercise as much within the condition of their disease. We want to delay the progression, if at all possible. I think the next one is the key, is to prevent exacerbations, because that is what lands them in the hospital. We want to do what we can to prevent that from happening. What to do when they do have an exacerbating event. Next slide, please. Some general consideration, goals of care. Goals of care, smoking cessation. And I cannot emphasize the next line enough. Review inhaler and instruct a proper use of an inhaler. I wish I had the slide up, and it's a teaching slide in my deck. I prescribed the patient the spacer device. We all know about that. And the inhaler, their rescue inhaler. When I did a follow-up on her, I said, can you show me your inhaler and your spacer device? And she was a little embarrassed, and she pulled it out, and she said, I haven't really used it. I said, why not? Because I can't get it to work. And a picture is worth a thousand words. I wish I could show you. She didn't know how to use the spacer device. She pulled out the actual medication outside of the plastic dispensing device, and she tried to put that into the spacer. And for me, it was an eye-opening moment. I said, okay, I prescribed it. I think I did the right thing. But the execution was so poor. In the sense that I had no idea how to use this. Your patients may not need another inhaler. They may not need another course of prednisone or whatever. They may simply need a spacer and you to teach them how to use their device. Keep that in mind. I already talked about an emergency action plan. It's so important for them to know what to look for and how they can reach you. Making sure they have oxygen if they need it. Think about backup power for them or backup O2. Winter storm, summer storm. If the power is down, they end up in the emergency room if they don't have a backup plan. For our patients, whether it's for CHF or COPD. And now, again, we talked about TCM. Hopefully, as we talk about all this, this is coming together for you. In terms of what we talked about, the billing and coding and value-based side. And now going into patient care. Right? Not only is there is value and money, if you will, in the coding and billing. But there's really clinical impact in terms of having that phone call 48 hours. Having that visit within seven days after discharge. Okay? Keeping your patients at home. Making sure that they got their DMEs, they got their medication. They know how to use them and so on. And the final point ties back to the first point about the goals of care. When they come home with another exacerbation of COPD. Have the hospice talk. You know, you guys are in this. So you should be comfortable having that hospice conversation and the morphine conversation. If it's appropriate. Next slide, please. Again, I asked you to refer you to the GOLD, G-O-L-D. That's the Global Initiative for Obstructive Lung Disease app. That will give you so much information. It will guide you in terms of, you know, how to manage stable COPD. Or how to manage acute flare-ups. Such as using a PRN, SABA, or SAMA medication to help them with an acute exacerbation. For long-term ongoing maintenance, maybe a LAVA, LAMA combination. or either one or a combination, most of our patients gonna need a combination drug. And the app will tell you the different Lavalama combination and which one are available as a dry powder inhaler or a meter dose inhaler, or which one are available as a nebulizer. So again, when we're done today, when you have time in the next couple of weeks, explore the app and use them as your guide as you take care of these patients. Inhale steroids, they can be used alone or in combination with a Lava or a Lavalama, but steroids can increase your risk of pneumonias, as I've stated on the last slide there. It's DGOLD, G-O-L-D-G-O. G-O, if you type in G-O-L-D, G-O-L-D-C-O-P-D into your search is the Global Initiative for Chronic Obstructive Lung Disease. Okay, next slide, please. Some add-on therapy, Rifumilast can be used in patients with symptoms of chronic bronchitis, not emphysema. And if they have frequent exacerbations, it's a pricey drug, and there are GI side effects related to this. Pulse azithromycin, for example, 250 milligrams, three times a week can reduce exacerbation of COPD. Not so much, the studies is perhaps through the anti-inflammatory effect of azithromycin rather than the antimicrobial effects of azithromycin. Remember the four points of medication management, right? Optimization was one of them. Because our patients are so complex, pulse azithromycin may not be an option to you because it prolongs your QT. And our patients are already on QT-prolonging drugs already, right? Your SSRIs, your antipsychotics, your amiodarone, to name a few. So that's where, again, get that working knowledge, get comfortable with some of these medications and their potential drug-drug interactions. Methylxanthines such as theophylline, I don't use that. I don't remember the last time I've used that at home to help with exacerbations. We do use a lot of antibiotics when they have a flare-up. Most often, if they complain, their cough is more productive or their sputum is more discolored. Steroids, pulse prednisone, we do use that a lot. I don't think there's a consensus regarding, for example, 40 milligrams for five days or discontinue, or a taper. I don't think there's a consensus if one way is superior than the other, okay? You may want to have some of this prescribed for your patients, such as antibiotics at home or pulse steroids at home. Have them just in case they need it. Again, having that action plan, take care of your patients, keep them out of the hospital, reduce your cost of care, and treat them where they want to be treated. I'm not trying to shortchange my patients. I'm not, no, that's not the point. Many of our patients would rather be treated at home, and we know that from experience. We're going to give them that opportunity and the option to deliver great care that's based on guidelines and treat them at home. Next slide, please. Other consideration of a COPD exacerbation, keep in mind a differential diagnosis. If, you know, is it heart failure? Is it heart failure and COPD? Is it pneumonia or could it be PE or severe anemia? That's why he's short of breath. Keep an open mind, okay? Short course of steroids, antibiotics we talked about, and then you can see if they're on the LABA, you might want to add a LAMA and then vice versa, and then add a, what I call an X or inhale cortical steroid if you have high eosinophil count, and then the rifulmin last that we talked about for chronic bronchitis patient with frequent exacerbations. Next slide, please. Other ways to manage shortness of breath, reposition the patient, make sure the oxygen is working. I want to talk about that in our cases later on this afternoon. Consider different medication delivery method. Again, there's so many different kinds out there now, right? Meter dose, dry powder, they have advantages, disadvantages. For example, your DPIs requires a certain inhalation force that some of our patients may not be able to do. So you may want to go to a meter dose inhaler or go to a nebulizer. Other symptom management, you know, airflow, benzo for anxiety, your opioids for dyspnea. Keep in mind, a lot of patients, which we'll talk about here, has CKD, and morphine might not be their best choice for dyspnea because of toxicity, right? And decongestant if they're volume overloaded. Next slide, please. Chronic kidney disease. I think I gave you the app that I use, it's KDGO, K-D-I-G-O, Kidney Disease Improving Global Outcome. They have a website and also an app. You can download that and get acquainted with its offerings there. Some general considerations, you know, manage your hypertension, control their sugar to a reasonable level, smoking cessation, salt restriction, fluid restriction, treat statin therapy if consistent with goals of care. A lot of our patients with CKD, they get hyperphosphatemic, and treat that with a phosphate binder. For hyperparathyroidism, treat them with vitamin D supplement if deficient, okay? Treat acidosis with sodium bicarb. Again, when they have heart failure and CKD, go back to what we talked about before, use an ARB, use an MRA. And now the new kid on the block is the HCLT2I's, okay? That not only treat your heart failure, but also delays your progression of your CKD. If it's appropriate, you can measure microalbumin and treat with an ACE or ARB. And then having that goals of care regarding renal replacement therapy, whether to start or to stop. And what would that look like if I stop RRT for my loved one? Next slide, please. Again, each of these could be a lecture in and of itself, but I just wanted to bring to your attention some of the related issues with CKD, which we talked about already, hypertension, hyperkalemia, hypercalcemia by hyperphosphatemia, fatigue, and CKD-related anemia. By the way, that's also a ACC billable code, I do believe. Next slide, please. Went to talk with a nephrologist, CKD stage four or five. Again, that's GFR-based. Again, you can get familiar with the different stages of CKD. We talked about ACC coding and billing to the highest specificity. That's where it comes into play. And also when you need to talk about hospice or if you want to go on RRT or not. I reached out to my nephrologist friend when I have refractory HTN, high blood pressure, and they're on five different blood pressure medicines, and I'm getting nowhere. I need their help. Hyperkalemia is a complication we run into, right? Remember they got CKD, and now we are diuresing them because of their CHF, and we are adding MRAs like spironolactone to follow guidelines, and now they're getting hyperkalemic. You know, what are my options there, and so on. And then if they have just recurrent volume overload and they're not making urine, and I cannot decongest them with a lube diuretic, then it's time to get a nephrologist involved. Next slide, please. So what are, kind of summing it up here, you know, what are some of the strategies for overcoming some of the challenges that we face when we take care of patients with multi-complexity at home? Knowledge base, know what you're talking about, know what your options are, know the interventions, know the guidelines. Prepare, think about as you do your EHR, as you do your pre-charting on your patients, think about what you may want to do. Is the patient due for a metabolic panel to check on their electrolytes? Is the patient due for an intact PTH because the patient's hypercalcemic from their CKD? Do some preparation work so that you don't spend a lot of time just trying to dig in your EHR or Googling in terms of, well, what should I do here? Use your EHR as your friend, and the mobile apps we talked about, you know, pre-populate if you can. We talked about the MEET documentation for ACC, but I encourage you to, we're thinking clinically now. The MEET documentation, you know, I used CHF yesterday, you know, put in your smart phrase. Is the patient on beta blocker, ARB, diuretics? Yes, no, yes, no. So that not only help you with documentation, but it also help you with patient care. Smart phrases we talked about, and the final thing is allow enough time. It's really hard to rush through a 15-minute visit with patients that are multi-complex, like the kind that we see. Next slide, please. Get comfortable, get familiar with the plan, do check, adjust. Multi-morbidity is a challenge, but it's very common in the kind of patients that we see, and the common conditions are heart failure, COPD, diabetes, and CKD. And the strategy is not only having some working knowledge on these diseases, but focusing and discussing on the goals of care, how to reduce their symptoms, how to optimizing their function, supporting the caregiver, and what to do in case of an emergency. Next slide, please. I'll stop here. Any questions before lunch? Paul, I think that was really comprehensive. Thank you. Thank you. And we'll as we start to segue out for lunch, because we will have about 30 minutes. And if you think of any questions, go ahead, raise your hand, put your questions into the chat. I want to thank Dr. Chang. All right. Thank you very much. It looks like people are getting some some some things out of that. And now we're going to move on for lunch. Melissa, can I just make one comment? As as, as your practice ventures into into primary care, and I encourage you to establish some relationship with some of the specialists, like a lung doctor or cardiologist or nephrologist and so on, not only as as a potential referral source, right, they see really sick patients. But also as a partner in managing these really complex patients, I still reach out to my cardiologist and nephrologist regularly, I just reached out to one now, like, you know, should I continue the ESA or erythropoietin stimulating agent because the hemoglobin now is over 10. So you reach out to these specialists to help you take care of your patients and help you get out of a bind when you invariably will find yourself in one. That's great words of advice. Thank you. All right, so let's go ahead and we're going to go to lunch for 30 minutes. Leave stay logged into the zoom if possible, just turn your camera and your mic off. And we will resume in 30 minutes with optimizing the daily operations of house call programs with Brianna. Thank you. All right, so welcome back. This is our last block of sessions for the day, for the week. It's been a really jam-packed couple of days, and I hope that you've come away with at least several pearls. So anyway, thanks, Sarah, for starting up the recording. We're gonna get going. I see Brianna there in her screen. So Brianna, let me advance to your starting slide, and you can take it away. Thanks, Melissa. Hope everyone was able to take a walk and get some lunch. This is our kind of last formal talk that we have, and then we'll get to do the patient case activities. So yesterday, what we tried to do is really lay the foundation for things you need to think about as you're developing your practice. I alluded to some of the core processes that you might wanna consider. What I wanna do in this session is talk a little bit more tactically about kind of the big picture and the big operations. I was trying to think of a creative acronym because Dr. Chang has an acronym for almost everything. I had the three Ps yesterday, the patients, the processes, and the payment. I would say, you know, we're gonna talk about the front and the back office, and I'll explain how I define those, the different types of team members. We gave you some specific staffing models yesterday. And then what kind of, talk more specifically about some of these core workflows. So intake, geographic scheduling, and how you're managing your day-to-day operations from a front and a back office perspective, those are really the big three. That's what you have to master for any house call practice, whether it's community, palliative, or home-based primary care. So we can move on to the next slide. So again, just kind of grounding us in the different types of professionals. I stressed yesterday that there's no one size that fits all. You're gonna have your clinical providers that are the core to your model and the care that you provide. They're providing their direct care for the patient. You're gonna have some supportive staff as well, perhaps. And then someone that's managing the practice management and the day-to-day operations, and then how you're managing all of those social services, coordinating care, and multiple people can kind of blend all of these roles. We can get really creative with this. We have a lot of time for this session, so would love to hear if anyone wants to share what your community palliative team looks like, or I know some of you do have home-based primary care programs as well. What does your staffing model look like? How are you accomplishing kind of this triangle of operations today, if anyone wants to share in the chat or unmute? So I'll take a stab at that. So it basically follows the same as this pyramid here. The only thing that we do a little different is have the LCSWs. We have a community resource navigators, navigators that assist the LCSW, but we also lease out the resource navigators who deal with all things social determinant to health systems around the community. That's wonderful. And you said your community resources coordinator, is that more of an administrative role to your LCSW? No, no, actually the opposite. It's the LCSW that is more the administrative role to the community resource navigator. Got it, okay. Perfect, thanks for clarifying. Great example. Andrea? Yeah, I can share as well. So our primary care is still quite small, but we're looking to grow pretty soon. So I'll speak more to our palliative side. It's similar as well, but we don't have quite as many resources available. We have a practice manager, we have what we call AAs. They're taking the phone calls, booking appointments, things of that nature. A couple of social workers. We've been struggling with staffing our nursing. So we're looking to be creative. We brought on an MA and an LPN, those types of things, just to try to help backfill those openings. And then we run an NP model for ours. Yeah, that's wonderful. Thank you, Angela. And I just like sharing those couple of examples too, because again, there's no one right way. There's plenty of practices that don't have RNs, medical assistants and LPNs. I find that LPN sometimes is state dependent. Like there's some states where that's really the primary clinical support role. Obviously social workers being a huge asset for the work that we do. So that's great. And having a practice coordinator or someone, whether it's a combination of a clinical lead or not, that can kind of really keep a pulse on the practice that's dedicated to the program, that's helping kind of blend all of these roles together. I think it's really important. Yeah, the other thing I was just gonna mention, and this is in case it helps anybody, but we have one nurse practitioner and a second one almost done working on their behavioral, like there's, forgive me, I'm not gonna say it properly, but they're being a psych NP. And so they're looking to build out maybe a small LLC where we can coordinate with them and just contract with them for when we need that service, but not have to employ them. But they're also employed with us on the palliative side. So we're trying to, how do we keep everybody in the family, right? And if possible, try to keep the revenue in the family whenever possible. Yeah, that's wonderful. Psychiatric nurse practitioners that are specially trained is a great example of kind of a specialty provider you might bring on. I know Dr. Siri actually has a psychiatric nurse practitioner in her practice as well. And so they're really managing their dementia patients, doing those cognitive assessments, behavioral health integration, similar to chronic care management. This isn't a coding talk, but there's a care management specifically for behavioral health. That if that's something that you're interested in, that is in that advanced coding handout as well, there's different care management opportunities when we're focusing on this behavioral health. So thank you for sharing. Anyone else wanna share anything about kind of how they're making this work or how they're thinking about making this work? Well, I can share. Our model is actually almost flipped from this. Our social services being the biggest part of what we do and the medical piece being the smallest part of how we've been operating. We're looking to increase the medical component, but we've had very good success actually with this model kind of flipped. Yeah, absolutely. And someone had brought that up in a past training too. And I think that's a really important point. I don't mean to make social services the smallest part of the triangle. Certainly we know that's a lot of what we do. So I think that's great. The comment in the chat about medical assistance. Yeah, I think I'm starting to hear that more and more now. Telehealth and technology for these kinds of patients really needs to be a tool and not necessarily a replacement for in-person care. But we're certainly seeing that, especially in a pandemic when patients were more uncomfortable with multiple providers in their home or providers were maybe uncomfortable about going into the home. I have seen facilitated telehealth models where the medical assistant maybe is going to the home and connecting via an iPad or whatever tech device they're using to do a telehealth visit with the provider. And it's kind of the eyes and ears and hands, if you will, of the qualified billing provider who's doing a remote visit. We will have to see how financially sustainable that is long-term. Again, most of the value-based care models do have telehealth embedded. They have already passed some initial legislation to extend telehealth after the PHE for a certain number of months. And then again, I think they're gonna, right now the public health emergency covering all telehealth is extended through October. I think it would be very surprising if it doesn't get extended at least one more time so we can use that tool for at least the foreseeable future. The challenge with that is it's always gotta be a billable provider that's doing that video visit. So it would need to be a nurse practitioner or a physician or someone that's involved. But certainly you could send a medical assistant to the home to facilitate that visit and do an assessment. And I will tell you in hospital at home we use paramedics to do that. And so it's very, only on certain days of their admission do we have a nurse practitioner in the home and then everything else is facilitated by a paramedic. So I think there's a lot of room for innovation with a billing practitioner being remotely located. Well, thank you all for sharing. I just kinda, I think number one, I think that'll help me kind of relate to some of these things that we go through. And I just, again, we learn as much from you all and kind of sharing strategies and how you're doing this as well. You can move to the next slide. So not gonna read you bullets. I just kinda wanna separate front and back office operations but certainly there could be one person or a combination of person doing these tasks and doing these things. So when I say front office, I'm talking about administrative non-clinical work, right? Who's answering the phones, who's handling the paperwork, who's doing the intake, helping with the geographic scheduling and the routing, calling for those appointment confirmations, medical records requests, all of those fun things. So you could have a medical assistant that's doing this. You could have an LPN. You could have a practice coordinator role that's doing this, lots of different options, but it's just kind of starting to think through these time-consuming tasks and how you're managing this in an efficient way. And again, the person that's doing this is gonna look very different. When I'm differentiating between back office, what I'm talking about is generally a little bit more clinical, who's helping with triage, which we're gonna spend some significant time talking about, DME requests, prior authorizations. They're all a pain, but they exist, and we have to have someone that's able to manage those in an efficient way, prescription refills, really being that liaison. And again, this could be, like we talked about more of those navigator roles or lots of different hats. Maybe you have this person keeping up with referral sources, lots of different operations, but who's kind of helping support the providers and doing some of these, starting to get a little bit more clinical. That's what I mean by back office operations could look very different. Thinking through, and again, there's no one right title. I know we did give you all some sample job descriptions. So feel free to take a look at that and see how you can combine it. A practice coordinator could also maybe be your business development or having some of those referral coordination meetings with your partners and helping with that. Or maybe you just have the care navigator could be a medical assistant and an LPN, and they're kind of doing both front and back office operations. Or maybe you just have an administrative person doing the front and then kind of a navigator for everything else. So get creative with how you do this. I will say it is important to understand your state scope of practice laws for both your nurses and your medical assistants, especially when you get into caring for patients in a facility setting. Sometimes medical assistants can help with minor procedures, sometimes they can't. I've seen some really great examples of providers who have a lot of group home or assisted living facilities where they'll have their MA kind of almost pre-round on their patients. They may be like getting the patient in the room, starting to get all the vitals, starting to do a lot of stuff, but just be mindful of that. Or if you do have an RN, certainly they're gonna have that higher level. They have some clinical decision-making ability and can help with more hands-on and clinical triage. Certainly could be a resource too. Again, with a lot of practices that have a lot of facility patients, sometimes they have a day of the week where just the RN is going out and facilitating some telehealth visits and doing some of that rounding as well. So you can get very creative about this. Patient service representative, just a fancy name for administrative assistance. Again, that front office support. I think a lot of people, I like to say process development. Here are kind of some of the big buckets that I think you have to have something in place to solve for and we'll spend a little bit more time talking specifically about a couple of these, but there's a difference between what's a required policy and what should really just be more of a standard operating procedure. I get a lot of questions about what policies home-based primary care practices have to have in place. I think a lot of this is just, there's protocols or processes or standards that you need to operationalize. Don't overcomplicate it unless it's regulated. It really doesn't have to be a policy. Intake, we're gonna spend more time talking about on the next slide, but what I would say here is do set criteria for which patients you're gonna take care of and then what happens if you have to discharge that patient or you have to dismiss that patient. We don't always have to get run over if it's truly an inappropriate patient. That's when maybe we're gonna have a three warning system. It's a warning conversation with the patient or the POA and then a certified mail dismissal letter, 30 days of refill and they're no longer in the program. That's a worst case scenario, but it's something that you wanna be thinking about. Same thing with no-shows, really, really costly when we're traveling and we're sending providers to the home, if they don't answer the door or your provider gets there and they can't get inside. That could be an education thing, right? My first thing would be like, did we check that we make sure we actually confirmed the appointment? Did we get ahold of someone before we just sent them out to the home? There's guardrails we wanna put in place. When I was working and many life's ago, it feels like now in the practice, and I would sometimes have those difficult conversations with family, they were so appreciative of just like, it was like, oh, we didn't realize how much of a burden and how much of an inconvenience that was. I'm so sorry, but what really happens is we need to make sure there's a caregiver there to open the door and can you coordinate with me and just make sure that we're scheduling these visits at a time that's available to happen. But you wanna have kind of a standard or what's your warning and dismissal and no-show policy gonna look like. We'll talk more about geographic scheduling, but again, that's totally gonna make or break your practice. Triage protocols too. Anytime we can reduce the burden of our providers, they have so much to do. These patients are so sick. How can we really use all of our staff to the top of licensure to try and streamline things and so we keep moving in an efficient way. Urgent visit protocols, I alluded to that yesterday too, but scheduling can be a little bit like Tetris. It's okay to push back a more routine visit that might be on a schedule for that day because you have to get in that post-hospital patient or that new patient that you just got a call about that sounds like they're in really dire need. So you need flexibility and kind of standards in place so that you can kind of play Tetris with your schedule and you can really make sure you're getting, like Dr. Chang said, who needs me today versus tomorrow or next week. And generally, even if it's a phone call and you have to call and explain that to a patient, that's something they're willing to do. Inventory management, it sounds silly, but you have provider supplies. Who's restocking the bag at the end of every day? Who's sanitizing all of the supplies? Who's reviewing the patient's schedule to make sure that if there's special supplies or something that's non-standard, you're bringing that equipment with you so you don't have to go back to that same patient the second time. Charging the equipment. I remember we used to have like bright paper colored signs, like reminding that all the staff had to walk past before they could exit the building at the end of the day, reminding them like charge laptops, charge the otoscope, charge the GPS, back when we were using a formal GPS, but make sure those things are in place. Really important because it could just really screw up your day if the provider goes to use something that's not charged or you go in your bag and it wasn't restocked and something's not there. So really important, even though it may seem silly. You may encounter bed bugs in the home and infection control. Dr. Sheng does a great job about talking about this. How are you gonna handle that? Paul, I don't know, what's your current policy with bed bugs? How do you handle that? Yeah, we try to, well, we don't have a formal screening process, but it's brought up by home health or a social worker or whatnot that it's alerting us to the potential of a bed bug visit. We tend to make those visits at the end of the day and we warn the providers that when you're done with a visit, you need to change your clothes and then put the potentially contaminated clothing into a sealed bag and get it cleaned. So that's our current policy. We haven't encountered that too many times in the years I've been doing this. Of course, I don't know. Should we talk about COVID, I guess? I mean, I guess we can't get around it fully. I was gonna go there. But, you know, we talk about infection control. So think about what your policy is for COVID, for screening. We have, when we make these outbound calls to our patients, do we screen them? Do you have symptoms, URI symptoms? Have you been exposed to somebody with COVID and so on? That can help your providers prepare for a visit or convert it to a tele-visit if appropriate or reschedule the visit, or you may need a full PPE and the battle gear, as I call it, right? So what is, you know, we're talking about process development. Talk it over with your team on how a COVID patient or potential COVID patient who has maybe not an urgent need but maybe somebody who's got an urgent need and you need to keep this patient out of the hospital for whatever reason, you know, what can you do to interface with that patient? And the other, piggyback on, and I'm reading my, trying to read my own handwriting, oh dear, about the patient dismissal policy. I think piggyback on that, Brianna, given the culture and the society that we're living in, you need a policy on de-escalation. What is your policy or talking points on confrontational patients, either at home or on the phone, and have a way to de-escalate teacher staff on methods of de-escalating? So I think it's important that you think about that as well. Two other things you were talking about, I think, you know, having those big pink sheets and so on. If you are venturing into a home-based primary care, will you be drawing blood at home? What kind of equipment do you need? What kind of processing do you need? Who's going to pick up? Who's going to drop off? How are you going to process the blood and all that. And then that gets into the whole inventory management protocol, who's gonna order the tubes for you and the needles and so on. Emergency prepare plan. I had to update for our providers who are on the road. Recently, we had a tornado warning here. So what are your providers to do if in the unlikely event that they are in a tornado situation? Okay, do you have a policy for that? You know, for the office, it's, you know, people head to the basement and so on. But what are your providers to do if they're out on the road? So we had to write a short little blurb about that for our providers, so they can feel equipped to handle emergencies. The other thing to keep in mind with emergency preparedness and safety plans, I know we have some people in Florida, right? Hurricanes and tornadoes and snowstorms in Illinois, that's what we get to deal with. But which patients are at risk, right? Who have oxygen or who may need electricity? I know some practices that have gotten sophisticated and enough that that's actually like a flag and a note within the EHR. They have a list of which patients they might wanna drop off, you know, emergency kit to when those things happen, but as well as how you're, you know, you're protecting your staff or maybe lightening schedules when there's bad weather or rescheduling or doing telehealth that day. These are all things you wanna plan for in advance because it's gonna go a lot smoother if you've talked about it as a team and you kind of have some guidelines put in place. There's a question in the chat, Brianna, about could you use an MA in the home and then have the MP, MD do that visit? Oh, we talked about that, yeah. Oh, sorry, yeah. So yeah, that's a facilitated visit. So as Brianna said, there's not one size fits all. I mean, you can use your MA in so many different ways. You can use it the way it's described here, or you can have a remote MA that does the phone calls and then never leaves the office. And the provider goes in after the MA has co-triage the patient, right, remotely. We were talking to a practice that contracts a nursing support from overseas. So there's so many ways to go about doing this. You have to look at what your budget is and what your needs are and where your geography is. There are just many considerations, so. Yeah, Paul, I wasn't sure if you were on yet when I was kind of talking about front and back office operations and the different positions and how different people can use it. I think we alluded to yesterday, sometimes some home-based practices have their providers travel with an assistant. Sometimes the providers are solo and we just have that office support remotely, like you said, that stays in the office. Do you wanna share a little bit how the medical assistants and the nurses work in your office? Yeah, so for my office, and then Brianna will talk about the back office later on in her talk here. So my nurses are in the back office and they do a lot of triaging, refills, ordering of DME, prior authorization. And yes, they do a lot of social work because we currently don't have a social worker in our office. So the nurses don't leave the office to go with the providers in the field. My nurse practitioners, they travel and see patients alone. I see patients with a medical assistant because of that, I can see more patients because I have an MA to help me rather than being alone. So the MA does so much with me in the field and Brianna and I have talked about this being kind of, I have this special relationship with my MAs because this is a very different kind of work, right? It's not just like rooming patients and I'm gone. I'm riding in a four by four box of an SUV with my MA day in and day out. We have to have a good relationship. We gotta know each other's kind of what patterns or nuances, if you will. So it's almost to the point of a unspoken, what we call it a dance. She knows my thing, right? She knows when I'm gonna stop talking and then when she's gonna start talking and does her role of whatever she does. And then I know when she's gonna stop and it's my time to take over and so on. So having worked with these MAs and I know them and we know each other, they can be so helpful when it comes to drawing blood, vaccinations, filling out form, discussing post, doing your annual wellness survey questions, your PHQ-2 or nines, your vulnerable elder survey. I mean, it goes on and on all the metrics that we have to do. Having an MA is so helpful to me while I'm examining a patient or going over the medications and the MA could be doing some of the screening tests and so on. And final comment I'll make is it can be so helpful when it comes to wounds. Some of our patients are debilitated or they have a body size that makes turning and whatnot exceedingly difficult. So having another pair of hands to help me, give me equipment, help me with needing a particular supply and so on. Having an MA, it's so valuable to me. So yes, I'm spoiled, sorry. Carl, I see your hand up. Yeah, thank you. So I'm gonna assume you have an MA. The nurse practitioners maybe don't have an MA. Is it because of the diminished reimbursement? I think there are a couple of, well, no, not, I mean, yes, it is less with a reimbursement with an MA. Well, let me just back up. Because I have an MA, I see more patients than they do. So there is a patient access issue that's being considered. Number two, I tend to see the new patients. So as you know, new patients take more time, blah, blah, blah. So that's another reason. The MAs see less patients, they do the follow-up visit. So I think it's maybe just by tradition, it has been this way that the docs in our practice get the MAs but are expected to see more patients than the nurse practitioners who do not have an MA and see less patients. The 85% reimbursement rule, I don't think it really was a major decision point for us rather than the doctors are meant to see more, see the new patients, set up a care plan for the MAs to follow in the future. And I think traditionally that's been our model. Okay, thank you. To add to that a little bit though, so it wasn't always like a one-to-one ratio with provide, I mean, for physicians. So sometimes it was personal preference because if you have an MA, the provider would have to come to the office to meet that MA, they would take a centralized car and a lot of the nurse practitioners in the practice preferred to leave and work from home. So that played into it a little bit, but I have seen NP-based practices where there will be certain days of the week, like their MAs are typically doing back office work if you will, but they rotate across their entire provider team and try and give them an MA one to two days a week. And then to Paul's point, usually from the financial perspective, we've seen to make it work with an MA, you would see two more patients a day. So if that provider is seeing five patients when they're solo, okay, I'll give you an MA two days of the week, but then you're expected to see seven patients or more. Right, right. So another consideration, you could certainly use medical assistance for nurse practitioners. I think honestly, when we were visiting this, some of it was personal preference from the providers on just how they preferred to work in the field and then not having to come to the office to kind of meet up with that MA and their office or end their days in the office rather than just going home. Agreed. Carl, I don't know if you had another comment that you wanted or a question you wanted to. No, we have been contemplating sending out MAs with providers for one, for allowing the provider to do documentation in between the visits while they're on the road, having the MA call the next patient while the provider is doing the assessment, all the things that you spoke to. So I was just curious as to if there was a specific reason why maybe your MPs don't utilize an MA and you do. So that's all. Well, thank you. Brianna said is correct. At least two weeks, I think we'd put pencil to paper in terms of calculating cost and what you need to see at least under fee for service, you need to see at least two more patients to cover the cost of an MA. Okay, that's great to know. Thank you. Yeah, and the other thing is there, we have, I mean, we're so short staffed. We don't have extra MAs currently. If they're, let's just say I'm on vacation. I'm out of town and the one MA traditionally goes out with me, then we offer, we want the MA to go out with a nurse practitioner. We want the nurse practitioners to see more volume when I'm not here and we need to put the MAs to good use. So we encourage them to use the MA and we want their volumes up when I'm out of town. Correct. Yeah, we've toyed with the idea of some parameds, but there's a price gap there between that and the MA. So, yeah. Thank you. Great conversation. Thanks for highlighting that, Carl. Yeah, to your point, the other really big efficiency piece besides just seeing more patients is someone being able to drive so the provider can chart and do documentation and callbacks in the car, really just maximizing their time throughout all working hours of the day. But we can, before we move on, so the last three we kind of talked about yesterday, how are you handling the billing collections and revenue cycle management? You know, you're not collecting copays in the home, things like that. So a lot of that can be, you know, a lot of EMRs have revenue cycle management components to it or maybe you have a third party billing company. We talked about some of the ways to stay compliant, but how are you kind of managing that, doing some internal monitoring and auditing, educating your providers when new updates comes out, kind of thinking about, you know, how you're avoiding risk and being as effective as you can. Next slide. So I wanna talk specifically more about intake because as I mentioned, I think it's one of the big three, right, that you have to master this. And there's a lot more to intake than revenue cycle. If you back up to thinking about when you first get a referral or you first get a call for a home-based patient, whoever's answering that phone or taking the electronic referral or whatever method it does has to go through a lot of steps. And that's why we like intake screenings, checklists, but before you even get there, you know, does this patient live in your service area even? What is their exact address and zip code so you can verify that? Do they have an acceptable insurance that you can take? Do you have their insurance information? Have you verified that it's active and actually correct before we're sending that provider out to the home and gathering some of those demographic information? We also need to understand how to communicate with that patient. Do they have a power of attorney or a family member that's involved in their care that we need to kind of make sure we're having all of that paperwork and forms and information documented on file? These are kind of just non-standard things that we have to think about when we're intaking home-based patients. And trying to do some of that screening to avoid inappropriate referrals. And the next slide has some examples, but just staying here for a minute, really, really important to make sure you collect all of that information and verify it and document it up front. I mean, even just having a wrong number in the patient's insurance as a data entry error, right? That's why we wanna verify that up front. It really kills your revenue cycle and just your process from the beginning. But Angela. I was just gonna throw in one caveat for everyone to think about. We do have a screening tool. And again, this is more on the palliative side, but we found that it wasn't intentional per se, but our team was screening people out versus using it to screen them in. So it was being used as a yes or no versus a tool. And it hurt us a little bit with some of our relationships. We have a few per member per month, this, that and the other. And so I think they were looking at it kind of from that fee for service perspective versus that MA plan of, they're telling you they want you to take care of this patient. So I just wanted to throw it out there of just, maybe check if you guys do have a screening tool, they're very helpful. But again, we were using it to find a way to say no versus a way to find a safe to say yes, if that makes sense. Yeah, I think that's such an important point. And especially with palliative care referrals too, we're not trying, I mean, the really the only hard no should be, are they not in your service area? Can you not take their insurance? Like the rest, when I say screening tool and the practices that I have worked with, most of the time, it's more just guiding questions, right? Like just trying to make sure it's an appropriate referral and an appropriate use of resources. We're not trying to, to your point, screen people out. That's it, we want to provide care to everybody that needs us as long as they're in our geography and we can take their insurance, right? Like those are the hard no's or, but that's a wonderful point, Angela, especially on the palliative care side. Because I know, you know, it can be hard when palliative care providers are called out and then the provider feels a little frustrated because they're like, really, this person just needed like a pull signed or like I'm being asked to be a social worker. This isn't really, you know, a true palliative care need. They just didn't know what to do with them. So it's getting dumped to me. So that's a great word of caution. The other thing I would add to kind of intake as a whole is this is an opportunity to get to know your patient and their caregiver and really explain to them and set expectations. Like there's so much change when we think about change management from them, from a patient that's not used to having services in their home to going to having services in the home. So even without, not in the EHR, it's great if you can put it in the EHR, but I used to have kind of like a scripting checklist, right, of things that our team would have to go over with a new patient. Because as much as you can do to make it efficient in that one phone call, that's great. Even if you have to call them back about scheduling. This is your appointment date if we know it. This is how our office works. These are the hours you can get ahold of us. This is how after hours works. Your provider's probably gonna re-educate and re-go over this during their initial visit and welcome packet. But this is how we schedule. We don't call you until the day before or a couple days before with a approximate timeframe. And we don't confirm until closer to the date so that we can make sure we're in the area. But really taking that opportunity to verify you have all the correct information. Are there any outstanding paperwork or things that you can be trying to get for your providers? And really just starting to educate the patient and caregiver on how your services work. And so that's a lot of information for staff to remember and to go over. Give them a checklist. Give them job aids. Have that documented. It makes it a lot easier when new staff are being trained as well. But I'll end my intake saga there. And they should be prepared to answer some basic billing questions too. You know, well, is this covered by my insurance? How is a house call different than an office visit? You know, my standard reply would always be covered under the same benefits as an office visit. If we're talking Medicare, it's, you know, Medicare covers your 80%. You know, you'll still have your potential co-pay or co-insurance that's billed to your insurance. They may sometimes have questions about those non-face-to-face services they see on their bill. So give your front office staff or whoever's answering the phone just some bullet points or maybe there's a billing person they talk to directly. But these are all things to keep in mind with intake. Yeah, Brianna, revenue cycle is so important and keeping your providers busy, right? And again, we talked about whether you're fee-for-service or value-based, about getting to the patients that needs you. Now, we've been making house calls since 1997. And you think that we got this down, right? No. Just this past week, I showed up at a patient's home and they already had another house call practice in, seeing them. And the wife thought we were home health. So that's another. So again, to Brianna's point, you know, have a refined intake process, have the appropriate questions. And when you make those outbound calls, you know, say we're a physician or provider group, we're coming to see Bob Smith and so on. And do you have any questions? And are there other providers seeing you and so on? And then be ready to kind of demystify this whole thing about house call providers and home health service. That's still kind of an ongoing battle for many of our seniors who are just simply confused about, you know, what kind of care. They just want care at home, but they're just confused about who's coming and who's going. Yeah, that's a great point. And that's kind of like, so here's some food for thought, not saying these are the end all be all of questions that you wanna kind of incorporate into that intake process. But this is kind of what I mean by those guiding questions that can get you, some of this is just really important information we need. But, you know, when was the last time you saw a provider? Do you have any other care providers in the home? You know, just asking some questions like that. Number one, you're gonna need to know who to collaborate with, if there are other providers coming in the home. I will say, I think it's gotten a little bit more of a risk for house call providers too, because now sometimes the Medicare Advantage companies have their own house call providers or other people going into the home. So that's why it's just helpful to ask the question. The other thing you need to think about is where you're gonna store this information in your EMR. So at least for like what we, you know, for lack of a better word, that 411 contact, who are you calling for appointments at what number if it's not the patient? And, or maybe you are calling the patient's home phone, but you have to call the daughter who's a nurse and lives out of state with visit follow-up updates. That needs to be some sort of central place. There's lots of different options for that address logistics too. Like you have to enter this code or parking guest parking in the back, otherwise you'll be towed or, you know, make sure you call when they're on the way because it takes the caregiver even, you know, a couple minutes to get to the front of the house to answer the door. So there's gonna be all of these kind of one-off logistical considerations that you just want to think about. Where's a central place in your EHR that you can store this information? And then here's just, you know, we're starting the process of gathering as much information for our providers as we can, so we kind of have an understanding as much as we can. And it's not going to be a perfect science, sometimes you have to drop everything and go see the patient. But as much as you can to collect and have all this information upfront before your provider goes in. But really important for us to understand who we have permission to be communicating with and who we should be communicating with, and making sure there's appropriate phone numbers and contact information and who that relationship is, are documented and stored in a central easy place in the EHR. Questions or thoughts here? Okay, I'm going to switch gears a little bit to triage, so now kind of thinking back to that back office and how can we really use our staff to the top of licensure, how can we reduce burden, this is going to heavily depend on the type of staff that you have in your office. So right, MA versus RN, those kinds of things. But as much as we can, based on their scope of practice, when I say triage protocols, I think where I'm not talking about, you know, telling the patient to go to the hospital or those long, complex triage protocols that sometimes we use in the hospital setting. I'm really talking about can you tell me what you think the biggest three, five phone calls that you get are? Like, what are your patient's biggest needs? What are the things that just keep coming up? And then how can we streamline our response to those situations? So there's a handout that you all have in the HCCI Learning Hub called Home Care Protocols, where we've kind of given you some examples. Again, they're not end all, be all, yours may be different. But for urinary symptoms, for example, if you had an RN, you know, a patient or a caregiver is calling about UTI symptoms, can they just order that UA and culture and start that process and route it to the provider as an FYI, while they're waiting for those test results? PTOT speech therapy, the patient already has home health, we already have that, and they just want to continue or they want to add on OT. Can they kind of set that up, order of referral, route it to the provider more as an FYI and close the encounter? We're trying to reduce those numbers of clicks, reduce the burden on the provider. Same thing with medication refills, you would be surprised. And I know Dr. Chang, when we pulled some in-basket data, it was really eye-opening on all the different types, but like, are you setting up 90-day referrals with 12 refills for standard meds? Whoever your clinical staff is should be at least setting up the refill and also verifying their correct dosing in the pharmacy before that's routed to the provider to authorize. So these are more just protocols, how can we use all of our staff to kind of set up those referrals, give verbal authorization, and we're keeping our providers in the loop in case they want to add or change something. But if it's really standard and these are like the top five or top 10 phone calls that you get, how are we thinking about that? And this is something that has to be a conversation, right? Your providers need to be comfortable with it. This is talked about in a staff meeting, developed together, and then talked about on how is it going, you know, how are we kind of really making everybody efficient, yeah, agreed by interdisciplinary team. How can everyone be involved, depending on, you know, the type of role that they have to really make workflows efficient. Paul? Yeah, I agree. We have too many touches. I already alluded to the number of in-basket messages that are inbound for the providers. So if there are protocols that you can create and the appropriate person is working at their appropriate level of licensure, by all means, discuss that with your team. The less back and forth, I think it's just so much better for everybody involved. And that's going to be a work in progress. I know, you know, some providers that have held messages or examples for staff meetings or to kind of talk about or, hey, we just changed this and I noticed I'm getting these three messages that, you know, we just talked about this should really be done before it gets to me. Like, it's not calling them out in a bad way or, you know, maybe you just talk to that person directly if you don't want to do it, if it's not appropriate in a group setting. But, I mean, this is a learning, right? And you're going to have to monitor to see how effective things are as you're developing these different comfort levels with your team. Next slide. All right. So geographic scheduling. We really honestly can't talk about it enough. We're going to talk about some specific technology tools as well. Again, it's going to make and break not only your productivity, but your provider satisfaction. I mean, you have wonderfully trained clinicians that are taking care of really sick patients. They don't just want to be driving all day. So how can we try and reduce that as much as we can? In your handouts in the HCCI Learning Hub, you have something called a sample scheduling guide. This is where I'm saying everything that we've talked about these past two days, develop your process and document it. So let's say you've used Erin's wonderful map and you have your 30 to 50 mile radius or wherever you're going to see house call patients at. You've then divided that into zones on which providers are taking which cities or which zip codes or even which areas. And now you're making a proactive plan for the week. So for every typical week, not that it's not going to change, but where are you on Mondays, Tuesdays, you're in these areas, Wednesdays, you have a lot of patients at certain facilities that are nearby each other. So that's your facility day. How can you really kind of put this into a plan? And that's also where you can note some of the preferences, like don't schedule more than five appointments a day or keep four appointments until the week before, you know, try and, you know, personal preferences, try and end closer to the provider's address when you're scheduling patients because they like to start with the furthest patient away and end their day closer to home. Any little things like that, you can have those conversations and have that documented so that whoever is scheduling and routing your patients has that information and is able to use that in an effective way. The more you can proactively plan on what areas you're going to be on what days, then after the provider sees a patient and says, I want to follow up in one month or three months, that scheduler could just be, or administrative staff, whoever's doing it could just be proactively putting that patient's follow up on a day when you're projected to be in the area. And it starts to build really nice reoccurring schedules where you're not geographically challenged. So next slide. In addition to actually scheduling the patient, you want to make sure that you're being effective about your route planning. So all of the patients that you have on the day, you know, making sure you're not crossing over. This is also if you have certain patients that have dialysis or have certain hours of the day they need to be seen by, that needs to be noted somewhere in the EHR so you can try and build, we try and accommodate patient requests as much as we can. But we still want to see patients geographically. Somebody's got to be seen at 9am, right? It's a hard thing for most of our elderly patients that all want the afternoon. But how can we know the kind of non-negotiable time frame limits and then really think about start and end locations and what's the most efficient driving route? We always recommend never giving patients, Dr. Chang, I think you like to joke around like sometimes you feel like the cable man, right? We're never telling them I'm going to be there. Tuesday the 12th at 9am. Give them approximate dates when you're in the home. Say, we'll see you in about a month. My office will call you the day before or a couple days before, whatever your process is. I really never recommend more than two or three days in advance confirming the date and time so that you have that flexibility. But then give them a window of time. So what our staff would do is say, okay, the first patient is we're going to be seen sometime between 9 and 11. And then each patient after that is 30 minutes apart. Second patient, we say 9.30 to 11.30. Depending on how rural or urban your area is, that might change. But you're always giving patients that window of time rather than an exact time. And then if they do need a more specific, you could offer to call them when they're on the way or something like that. But you want to kind of build flexibility into your schedule and make sure that you're mapping out your driving route. I'll show you some tools to do that. But really important to kind of be mindful of that. Your providers that are traveling alone too. Again, there's a lot that goes on during the day. It's going to be really hard for your clinical staff or even for your providers to not have that pajama time, as Dr. Chang says, or that bedtime callbacks and messages if you're waiting till the end of the day to try and address all their needs. Can you stop when you're not driving in between patients just to check on urgent or have your staff? Maybe this is, again, that office protocol you put in. If it's important, you need to call me or text me so I can call you to give you real time verbal advice in between patients. How are you trying to build in a little bit of that break time so that you can address things throughout the day and you're not just waiting till that critical afternoon time when you're done with your business? We can go on to the next slide. Again, kind of planning those schedules can really be like Tetris. I think the point that I want to make here too is about appointment confirmation. If you can't get a hold of the patient, that should be a discussion. Do we go to the home if we don't get a confirmation or do we cancel the appointment and reschedule and leave a message and say that we're not going there? You can let the provider know too. Sometimes they know their patients and they're like, oh, yeah, I know Mrs. Smith is always home. I'm not worried about it. I'll go ahead and see her even though you didn't get a hold of her. But most of the time, we recommend not going out to the home if you haven't confirmed the visit date and time. So think about appointment confirmation in your process as well. Again, don't finalize that schedule too far in advance. That allows you to accommodate those acute and urgent visits if you know what. Again, that's a partnership with the providers. But these three patients are really, I just saw them last month. I don't have any messages about any urgent concerns going on. I'm going to bump them to next Tuesday when I'm in the area so I can fit this patient in or this post-hospital visit in. Those are the kinds of things that should be going on that can be a nuisance. I think it was Allison that shared in the chat yesterday, this is one of your stressors and your pain points. Logistics and scheduling is certainly a lot more complicated in home-based care. Questions or thoughts so far? I know I'm throwing a lot at you. So I cannot personally recommend or endorse any of these solutions. But people always ask me what health care providers are using. So these are all of the technology solutions that I'm aware of that health care practices have told me that they're using. They have different costs associated with them. CareLink is one of the most more expensive. It's really a practice management and routing software that has a cost per provider that was developed by a health care practice. Road Warrior, I used to use the app for free when I was planning driving routes. You can put in up to eight addresses at a time. And then you can say where you want to start and stop and then hit Optimize. And it optimizes the driving route. And it'll also track mileage. So if your providers are reporting mileage and things like that. BatchGeo and Maptiv, you can sometimes pay for a temporary license too. So what it does is it essentially gives you a template, a spreadsheet template in Excel where you enter all of your patients or you export from the EHR of your patients and their addresses. And then it plots them all on a map. So maybe you then just need to do that in the beginning to define your zones and not use an ongoing. I know many health care practices that are just, you know, they plan out their areas manually. They have that kind of scheduling guide. And then they just use Bing and Google Maps. Google Maps business account, you can actually plot patient locations with different colored flags or pins, if you will, and then keep that updated ongoing. I know a couple of health care practices that have a Google Maps business account, which is supposed to be HIPAA compliant. And then they use it that way. My route online is a newer one I've heard of more recently that's supposed to be a little more low cost as well. Any, if we can go back, sorry, just for one second. Anyone using anything that's not on here? That's okay. Sometimes it's just homegrown. I think back in the 90s, Paul, you and Tom were drawing, I have horrible visions of like paper maps. So we've come a long way with technology. Might as well use it to our advantage. Carl, were you going to add something? No, I was just laughing to myself. I've been doing this since the 90s. And we used to use MapQuest. There was so much paper in a car trying to find a map. Oh, I've seen it. Yeah, it wasn't even that long ago. I had talked to a practice and they were like, can we talk about geographic sketch? And they literally showed me. They like on their Zoom were like showing me all these. And I was like, oh, no, we can't do that now. Let me help you, please. We took down a whole forest just on MapQuest. Yeah. Hey, I mean, it works, right? When we didn't have technology, we had to do something. Right. All right. So switching gears a little bit. Those are kind of my tips and tricks for geographic scheduling and what map-based tools might be out there. Until five years ago, Dr. Siri. Yeah, I hear you. Interdisciplinary team meetings. So we've talked about this. Again, this isn't an end-all be-all agenda, but just kind of giving you some ideas on how you might structure your team meetings. Some practices do an IDT meeting weekly. For example, I believe Dr. Siri's practice does a weekly IDT meeting. And then once a month, she tries to do more of like an educational update for her providers or things like that. I know Paul's practice has monthly staff meetings, one that's more operations focused, one that's more clinical. Lots of different ways you could do this. Paul, anything you want to share on kind of staff meetings or IDT meetings? Yep. Before I get to the IDT, the team meetings, let me go back to the geographic scheduling thing. I think that was super important under fee-for-service because we wanted to see as many patients as possible. It was about volume. But as your practice takes on risk, as your practice gets paid in an under different model, perhaps, the geographic scheduling may have to be counterbalanced with, as I said before, who needs me today? OK. You might need a different... How can I illustrate this? OK. You might need a different dashboard, for example, that lists all your high-risk patients. Let's just say it's based on ACC score. And you have a dashboard with all your patients with their ACC score and the last time they were seen. Maybe it's risk-based visit as we look into the future in addition to considering your geographic scheduling. No, I'm not advocating your provider driving 70 miles a day to cover your patients. But just to keep that in mind as we talk about geographic scheduling, which is still, I think, an important consideration. But you may superimpose another layer now of who you need to see based on acuity. Regarding IDT meetings, Brianna was right. We have a meeting once a month. That's more operational, working out the kinks, clarified misunderstanding or whatnot between front, back, office, and the providers, and so forth. And then we have a meeting that's more educational. For example, the past... So who came to speak with us? Memory care specialists, a nephrologist came to speak with us. An endocrinologist came to discuss. Pulmonologist and a cardiologist came to talk with us about all the things that we talked about today, heart failure, dementia, and diabetes, and then how to work up like a adrenal nodule, thyroid nodule, and so on. So it's an educational session for our providers. Again, it's about that resiliency that I talked about, making sure that you are equipped, able to handle what's going to be thrown at you from a multi-complex standpoint so that your providers don't feel overwhelmed. Yeah, last thing I'll highlight on this slide, too, is just when we think about that team building and retention, I love either starting a meeting with a patient story or a thankful patient letter or a comment that someone can share and ending a meeting with recognition. Your team might want to be recognized in different ways. Dr. Chang's office has a couple jars. You might even have an anonymous survey link where people can put in suggestions or comments or thank you comments, but really just trying to build that team morale and remind everybody while they're here and sharing good outcomes, not as a way to scrutinize, but also just say, hey, look at the impact that we're making, while also fostering that continuous quality improvement kind of mentality of the team that we're all learning together and we know we can always get better. So we're going to talk about things that process breakdowns or things that maybe didn't go so great, but we're also going to recognize what's going really well. Yeah, so the jars that Brianna was alluding to, so I have three jars. They're labeled as such. One is the first jar is the thankful jar. We live in a culture of outrage, right? Where any little thing will make us, okay, disgusted, outraged at anything. Let's foster a spirit of thankfulness, thankful for each other, thankful for the work that we do, whatnot. So that's the first jar. The second jar, yes, I already told you I'm a Star Wars fan. The second is the Jedi skill jar. We all have Jedi skills. What can you show me or share with me so I can become more of a Jedi master, right? We all have those skills. I don't know everything. Let's learn from each other. And the third jar is a wishlist. I wish things were, and as you as leaders can take that wishlist and see what you can do to make it possible. There are things I just, I can't fix. I can't fix the hiring crisis. There are things I cannot fix, but there are other things I can fix that I can implement. And you as leaders can make your working place a better place for your employees where they feel like their work is being, is important. They're just not a cog in a wheel and they're less likely to leave. Yeah, great point. The next slide. So the other thing you might want to consider in addition to your IDT meetings, whether those are weekly or monthly, is just a quick huddle. Honestly, even a daily huddle, no more than five or 10 minutes, even if you have to do it virtually, everyone jumps on Microsoft Teams or Zoom or something like that, that just goes over with our plan for the day. Were there any changes? Where is everybody? Do the providers have any immediate concerns that people could be working on or doing things? Sometimes even just a quick huddle in the morning. If you can't do it daily, maybe weekly, if you're only meeting as a staff or as a team monthly, huddles can be a great way to, again, communication is key. If we're not all, if the front office and the back office teams aren't communicating and they don't understand what's important to each other. That can really mess things up. And again, when you have a lot of, when you don't have people that are all in an office together and everyone is working remotely or just leaving and starting their days from home, sometimes just a quick touch base with the team, a daily or weekly huddle can be super valuable to kind of keep that connection and that communication. I think we've kind of gotten away from, you know, depending on unless you really do have a physical office space, but sometimes I've even seen the next couple of slides are examples of what's called a huddle board, you know, keeping track of where providers are in each area, how many patients they had in the day so that the scheduling and the nursing staff knows who would be available for more of an immediate add on. Centralized phone numbers, the care management and who's on call, you know, who's, you know, things like that. Just having a centralized place where all of the team can find that information. The next slide is a little bit more advanced of an example. They really kind of kept their metrics on there, you know, recognition, heads up, all of those kinds of things. And they did more of a longer huddle on a weekly basis with all of their teams. And they would kind of meet around this board for a centralized place. So just some other examples of creative things you can do if you do have a physical office space. I alluded to this yesterday, too, but, you know, really taking the time to kind of do that root cause analysis or that investigation when something goes wrong. You know, do team members really understand what everybody, everyone's role in the practices? Do they understand what everybody does and who's supposed to be doing what? Or even maybe it's a confusion of in baskets. So hopefully, you know, you have some sort of different, could be in basket, could be work queue, could be whatever electronic way different tasks are assigned to different team members. You know, if you do have multiple clinical staff, are they, you know, tagging themselves or liking or noting when something's being worked on so two people aren't doing the same thing at once? Or is it really something that, you know, has come up that you need to have a larger discussion on and try and figure out, you know, okay, is it time to hire or do we need to rework this process? But really kind of understanding and making sure you take the time and have a, whether it be anonymous or formal way for people to kind of say, hey, this didn't go so great today or, hey, I'm struggling with this. Can we look into this? And then have somebody designated to kind of take that and follow up on it. I know one practice that used to actually have, they were really big into lean and process improvement. They used to have like an actual like action form that would be assigned to somebody and then they would work it from there and kind of evaluate it and share back with the team. So, next slide. Dr. Trang and I, a while back, were trying to talk about what's the secret sauce of a great team, of a house call team? What does it look like when we're kind of doing the best that we can and we're really fostering a culture that's effective for our patients so that we can all show up in the best way possible and, you know, do the best we can and take and be, you know, do well with communication and team building and all of these things. And this is kind of our recipe for a secret sauce, if you will. You know, open communication, defined roles and responsibilities, buy in on practice mission, good relationships with your partners and your facilities. As much as we've said how great assisted living facilities are, there's also challenges with working with, you know, those kinds of partners and making sure that you're staying connected. Willing to change and flexibility. You know, I used to have a mentor that said the only thing that's constant in healthcare is change, right? Like we're constantly adapting. It could be kind of frustrating for staff if you're constantly changing roles and doing things differently. So, how are you kind of staying connected on that and really fostering that spirit of learning? Other things to keep in mind as far as pre-visit workflows for the providers, and every provider has their own tips and tricks, but I'll highlight just a couple here. Assisted living facilities, really helpful to have your staff call one central person, whether it be a direct D.O.N. or someone to go over all of the patients that are scheduled to be seen the next day. Can the first patient be in their room at 9 o'clock or 10 o'clock or whenever the provider is going to be there, or can you use, you know, staff to make sure that as much as you can, you're not trying to chase patients down in the lunch hall or things like that. Ask home visits, you know, making sure they're confirmed, but also reminding them to have their medications out, or maybe you have to call on the way to remind them to put the dog away or the cat away. Those little things, all these things that can keep us efficient. Post-visit workflows, you know, Paul, feel free to chime in if you want to add anything here, but I think just kind of reiterating the teach-back method, there's a lot going on, just like we're talking, and it's a lot to take in. It's a lot to go on for our patients, so are we recapping? Are we explaining? Are we having somebody follow up to arrange any testing or referrals they need? We're kind of making sure the patient understands that plan, that it's aligned with their goals of care, and we're communicating with everybody that's involved and we're communicating with everybody that needs to be involved in that patient's care as well. Yeah, do as much, you know, for me, do as much pre-work as possible, chart review, pre-ordering labs, and so on. There's so much to address at our patient's visit, and at least for me under fee-for-service, I'm always pressed for time, so getting pre-work done, getting my mindset ready when I go on to see the patient, that'll help me stay focused and help me deliver the care that the patient needs, right? I think somebody said, attention is the rarest and the purest form of generosity. I try to be generous with my time, and by that, I need to pay attention, so I need to stop scrolling. I need to stop clicking. I need to do my best to look them in the eyes and pay attention to let them know I'm here for them. Yeah, great. Dr. Cheng is great with quotes. I love that, Sarah. Thank you for your comment. Shifting gears to wrap up this session just a little bit, we can't, you know, really wouldn't be fair if we didn't talk about safety. Again, we can go to the next slide. Most of these patients are so grateful. Their families are grateful. You're their lifeline. You build a relationship with them, but we do need to be prepared for that one or two percent when maybe we do get ourselves into an unsafe situation. We need to understand that going into the home does have some risks that, you know, clinic-based or hospital-based providers just don't have to, you know, have that same sense of awareness, so how can we make sure that we're keeping all of our team members safe if we're sending them into the home? Do we have a plan if something is not feeling so right or not feeling so great, and how do we do the best we can to kind of avoid any unsafe situations in the home? So, I believe we're going to do a short video. This is Nora, and while we watch the video, take note of what are the good things that she did and what are the not-so-great things that could have gotten her, you know, could have gone better. Yeah, just, you do have a worksheet in your learning hub about comparing the good and the about comparing the good and the bad. You don't need the worksheet. Just think about it, and we'll come back and talk about it. Meet Nora, a nurse practitioner who's on her way to a home care visit with Sylvia, who lives in a rent-controlled, fourth-floor walk-up apartment. Nora's getting ready to leave for the appointment. She takes some cold medicine before she goes. She has a bag with her tablet PC and charger. Here's her box of supplies. After packing up her car, Nora checks her navigation app to remind herself where she's headed. Then, she checks the weather app. She text messages Reg, the coordinator at the office, to let him know she's getting on the road for the day. There's no response, but Nora heads out. Ah, here's Reg with the text message response. Hello, Tony. This is Nora from House Calls. I just wanted you to know I'm about five minutes away. Can I ask you, Tony, to make sure that the cats are secured in the bathroom before I arrive? Thanks to Reg's message, Nora avoids the accident area and arrives at Sylvia's on time. She parks in the first available spot, since Sylvia's street is usually tough for parking. Nora's phone shows it's 8 p.m. and Nora's phone shows it's 5 p.m. Nora's phone shows it's 8.20 a.m., so she thinks she can be out of the spot before 9. Nora gets out of the car quickly so she won't be late. She gets all of her bags onto her rolling cart. She places her phone and keys in an accessible pocket. Her shoe covers go in her other pocket. It's a quick walk to Sylvia's building. Sylvia's stairwell light is out again. Even though Nora's been to visit Sylvia before, she shows her badge before entering the apartment. She also pulls her shoe covers out of her pocket and slips them on. Hmm, Sylvia's daughter wasn't able to get both cats into the bathroom. At the end of the visit, Nora goes through her mental checklist to be sure she's repacked everything she brought. It all goes back on the cart so that she doesn't have to struggle down the stairs. Sylvia's daughter, Tony, grabs a flashlight and escorts Nora down the stairwell. After Nora leaves Sylvia's, she notices her cell phone is below a 50 percent charge. She pulls her car charger out of her glove box so she can charge on the way to her next appointment. She remembers to text Reg before she starts the car. All right, thanks for the video, Melissa. So anyone have any observations from the video, comments, things that you're like, oh yeah, I got to remember to do that, or other things that probably weren't the best move? I liked certain aspects of the coordination between her and the office, making sure traffic, you know, was conveyed. I thought that went really well. Yeah, absolutely. That's a great example. I will, you know, admit this is a little bit older video, right, the cart, and yes, so absolutely no texting when driving. If you have Bluetooth and you're calling someone in the way, you can text them. But I think someone in the way, I will say a lot of providers say like that's their secret sauce, you know, trying to make phone calls in between visits or communicating with their office in between visits. So there are ways that you can do that. You know, she could have maybe sent that text before she started driving, and that would have been another way to go about that. But certainly not texting when driving. Other things you guys noticed? We often talk about the power balance in home-based primary care when you're going into a patient's home and really recognizing that dynamic and that change. So she was respectful. You know, some providers wear shoe covers. You know, she made sure to introduce herself and show her back. Badge, excuse me, when she was entering the home. Yeah, Tasha wearing a diamond ring, you know, and she didn't talk about cleaning the equipment, you know, keeping the keys hanging out of her pocket so they might fall out. All things that we want to, you know, think about as in and how to do that in a more effective way. So making sure that things are secure. Some practices like their providers to be identified, some don't. Some wear plain clothes and don't want any things on the vehicle. You could also see whatever medical bag you have, it's concealed. So, you know, people can't see what you're carrying around, different things like that. But, you know, making sure things are secure. You want to be able to get to them quickly. We definitely, obviously, wouldn't want to be parking in a spot that, you know, is at risk of towing or trying where you feel like you have to be rushed in the visit. That would be another call out. Yeah, I remember that cold medicine she took. Yeah, right. Especially now, we wouldn't be sending our provider to work or unless having them do anything besides telehealth visits, if they were if they were not feeling well. Yeah, it's so hard to resist texting when driving, right? Let's be honest. Yeah. Brianna is right. We've encountered so many practices through our years at HCCI. Different practices have different styles. Some wear uniforms, others don't. Some wear badges, others don't. There are practices, if you're in like the inner city area, especially with winter coming for us in the north, you know, we have a lot of people who are in the inner city area. Especially with winter coming for us in the north, northern latitudes here, that they don't make house calls after like two o'clock. They don't see patients because it gets so dark. So think about your geography. Think about the, I'm sorry, the clientele that you're serving and the places that you'll be traveling to. And I think, Brianna, you might be talking about, you know, safety. There's a safety app that you can download on your smartphone. Some people like the safety app because we know where you are. Some people don't like the safety app because we know where you are. You know, you've been at that Starbucks for a long time, you know, so they're different. They're different take on that. You might want to talk with your staff and see what their acceptance rate of that as well. And then I think we're going to talk about like the emergency code, like, you know, the Dr. White thing, right, Brianna? Yeah, absolutely. So again, kind of thinking about process and what you can put in place, you know, I do know a couple, I wouldn't say it's super common, but some house call practices that use like Life360 or location tracking apps, and they make it optional so that you would know, you know, and they turn it on and off, you know, just when they're working. So you would know where your providers are. Some practices will order personal safety alarm devices or things like just small things they can put on their key chains. So there's lots of different things that you can do that. But really just important to be observant of your surroundings, right? And like we used to tell our team members, like, if you're uncomfortable for any reason at all, you don't need an explanation. I don't need you to be polite. You get yourself out. You try and, you know, have a clear pathway between the door, you and the door at all times. And if it was really an unsafe scenario, that would always, we could always go right to dismissal, you know, or, you know, like Dr. Chang said, sometimes seeing people there in certain hours or requesting a joint visit, if it's not so extreme, you know, it depends on the situation. But you really have to trust your gut, talk to your team, you know, and know they can always come to you with concerns and always be supportive when it comes to safety in particular. If you go to the next slide, I think these are some of the other things Dr. Chang was alluding to. So having a code word to like Dr. Chang mentioned, Dr. White. So if for whatever reason a provider ever felt unsafe in the home, we would say either call and say, I need to speak with Dr. White or text Dr. White, and that would alert the office that something unsafe was going on. And if they were on the phone, it would alert them to say, do you need me to call the police? Are you in a safe place? Can you get out of where you are? Again, those situations are few and far between, but how are you going to proactively plan for that? You might even, you know, there was a time when we were talking about safety for the first time that we had one of the local police officers come and talk to the practice and just kind of give them tips on how to deal with confrontations and unsafe situations. If they're brand new to the home or your providers feel like they have a little anxiety about that, maybe you do want to have some sort of educational session at a staff meeting or do something about that. But always, you know, just kind of be aware before, during, and after and kind of have a plan for your practice. Weapons in the home, that's another thing. Sometimes you can have like a, what's called a, you could even just Google this, like a patient bill of rights that it goes into welcome packets. So these are the things that you are entitled, you know, that we expect from you, you know, and these are the things we expect as team members. If you do have any weapons or firearms in the home, it's our policy that they have to be locked up and put away. We do ask that your pets are locked up for the visit for infection control purposes and not that we don't love your pets, things like that. But we kind of are going over our standards with patients and some practices even have that sign and keep it on file. Paul, were you going to add something? And here. Yeah. So something came out this week. Oh, you may need a policy on being videotaped at home. With all the surveillance that's available at the home now, you may need a policy that delineates whether you're, you know, for Northwestern, we don't allow videotaping of the visit, but it's just something to keep in mind. Well, and for that, remember the prevalence of rain cameras or other similar surveillance, you know, I mean, if you're, your conversation on the front porch could be recorded. Yeah. Yeah. That's a great point. So again, safety is definitely a topic for IDT meetings or some sort of kind of formal guidance that you should just talk to your team about. You know, you can arrange scheduling based on certain things if needed and really just always support your team members, you know, tell them to trust their gut and you'll support them and figure it out if they have to leave a visit and excuse themselves without much reason. Paul, someone asked kind of like, what's the concern about that? I think being videotaped, you know, I think it's sometimes it's a concern, sometimes it's not, but do you want to share? Yeah, I'm concerned about patient confidentiality. If it's being recorded, where's it being stored? If it's on ring, all my conference, even Alexa, Alexa is always listening. Okay. Where's that information going from your digital assistant? Where's it being stored? Where's it being stored? And do you really want somebody recording your conversation with your patient? Even a delicate thing, delicate things like end of life conversation, do you want that recorded and being stored offsite in a potentially probably unsecure or not HIPAA compliant storage site? So that, that would be my concern. And I think it would, it would really make me feel uneasy if I know that every word I say is being taped. Oh my goodness. How old am I? Being recorded, right? To me, that's an intrusion into a very private and intimate space between me and the patient. Thanks, Paul. Other questions or comments before we end this session? Well, with that, I'll turn it back over to Dr. Cheng for our next simulated house call session. All right, we are on, I think this, this is the final, this is the home stretch. And what we're going to do is, you know, I talked about going on a ride along is the kind of the only way for those who are new to house calls, get that experience. But since we cannot have a real ride along, we're going to try to do a virtual or simulated ride along. We're going to, we're going to make three house call visits. We're going to go through some decision points that you're all going to have to make. And then live with the consequences, well not live, take a look at the consequences of your decisions and what you may do differently or may do or may prioritize one or over the other. Remember, these are multi-complex patients. You have competing interests. What do you take on first? All right. And then Brianna, as always, she'll finish the session with, you know, are we billing this correctly, billing it to the maximum, whether you're a fee for service or value based care, ACC or time-based visitor, whatever it might be, she's going to bring it all home from a financial perspective. Next slide, please. Okay. So you have a more extensive description of Ralph in your, and Melissa, and you can help me here, help the learners find the, I'm going to find it myself here. Yeah. Let me ask Sarah, if she can put some instructions in the, in the chat, but all of these cases are in your HCCI learning hub. And I'm also going to have them available here to, yeah. So I'm going to pull up on my other screen here. So Ralph is, he's a 76 year old African-American man with oxygen dependent DOPD. There's an ACC coding, pulmonary hypertension, pulmonary hypertension. There's an ACC coding opportunity, heart failure, HFREF. There's an ACC coding opportunity, and you're seeing patient at home. You've been seeing him for a couple of months. He got involved because he was a frequent user of the hospital. There you are proving your worth, having that elevator speech. Why are your services important to prepare whoever you're talking with? You Ralph and nephew Reggie have been working on a plan of care. Remember it's always a dyad patient and caregiver so that the hospitalization and ED trips can be reduced. Okay. But he had increasing shortness of breath and he had an ambulance call a couple of days ago and he was kept at a hospital and now you are doing a post discharge visit with him. Hmm. How are you going to code that? Okay. So you can, there's, there are more extensive information in your learning hub. Here it is. And you can look at his chief complaint, follow up at the hospital, admitted for shortness of breath. And you can look at his past history, medical history, again, keep all the diagnosis in mind because Brianna is going to talk, help us code correctly, right? I'll just highlight, you know, oxygen dependent atrial fibrillation. All right. We talked about all that. A half rep for the EF of 40, pulmonary hypertension, CKD three, you can do, you can sub, you know, divide it into three A or three B. And you can look at the immunizations and so on that could be important for your quality metrics. Right. As you're again, showing your value in taking care of these terribly sick, complex patients at home. Social history, very important for our patients be just because Ralph wife, his wife died lives. He lives alone. His nephew Reggie lives a couple of minutes away. He does check on Ralph and their Ralph's sister helps with the groceries but he still smokes and he's on oxygen. His neighborhood is not the best. He is a veteran. Keep that in mind. See these are all clues. Reggie doesn't always pick up his medication because of money. Okay. As you're doing all this intake, absorb all of that in, you know, how is billing and coding access, compliance, safety, and all of that. Okay. I'm not going to go through everything on the review of systems here other than just highlighting some things he's got showing us a breath. I've been feeling down. I'm not depressed. I still like sitting on a porch with my friends in the evening. His legs are swollen. Take a quick look at his medications. I'll let you absorb some of that in. Remember the stuff that we talked about today, about heart failure, the four pillar drugs, you know, ARNI, ACEs, ARBs, your beta blockers, your MRAs, and your SGLT2s. What I didn't talk about is, again, on the app, you'll talk about on the ACC app, Treat HF or Guideline app, it talks about the starting dose. And then there's also an optimal or goal-directed therapy dose. For example, the Carbadol's 3.125 is pretty low. We might be able to push that up. Just something to keep in mind. The screening, again, you don't have to do all of this at the first visit. It would just be too much. Think about what needs to be addressed at the follow-up visit, whether it's cognition, whether it's PHQ-2, or are we worried about him falling down, and so forth. You can go down to social media. Again, I'm not going to take the time to review all of the information there, but just kind of go down, take a glance, and see if there's something that jumps out at you. I'm looking at the financial status, because he doesn't use his medications. His physical exam, you can see there, his height and weight, and look at his O2. It was 76. And then got the oxygen, it came up to 92. And the exam, just highlight a couple of things. He's got a regular heart rhythm. He's got elevated JVD. He's got some conversational dyspnea. He's got some crackles, and he's got some wheezes. He's got an HJR. He's got some pain behind the right and left knee. These are not red, but he looks like he's got some DJD. He can move all of his extremities, but he's got edema with the venous stasis changes. Take a look at his advanced directives. Okay. His full treatment, attempt CPR. And just think for a minute here, even just jotting down some notes. What are just some symptoms? What do you want to treat? What are some conditions you want to tackle at the visit? Again, focusing on the four Ms. We're going to try to tie all of this together, the four Ms. What matters most? Mentation, mobility, medication, and a multi-complex, sorry, five Ms. The four Ms plus the final M. So as you think about Ralph and his conditions, his complaints, what are you going to do first and so on? Keep the four Ms in mind. All right. Questions? Melissa, should we move on to Betty then? Yeah, just a couple points. You know, in the last, those were the notes from the last visit, and your office has advised you that Ralph's brother passed away since the last visit. So this was just kind of the plan for today's visit, right? Yeah. Okay. So you're following up on a post-hospital, go back one second there. And we talked about, you know, he's got COPD. We talked about emergency planning, right? We talked about the fact that a time of transition, it's a good time to talk about advanced care or review the advanced care planning or goals of care. And then he, remember he said, you know, this is the other one of the Ms. He's feeling down. His brother died recently. Is he trying to give us a clue or a hint that he might not be doing well emotionally? Okay. All right, Betty. Betty is a younger patient. She's quite overweight. We're there to establish care for our patient, and this is a real patient. I still remember her to this day. She's got multiple medical problems that you'll see in a little bit, severe physical limitations. She's depressed and she's got anxiety. She has not left her basement for months. She can't go up the stairs. She's really weak. She's in a lot of pain, and she has a lot of fear. We were called to see her because just like I got two new referrals for next week, a patient's too weak to get out of the home. They need somebody to come to the home to take care of her. So Betty is similar to the other patients that I'm going to be seeing or I have been seeing. Next slide, please. Again, I'll refer you to the learning hub regarding Betty. There's the intake. There's the cheat complaint. She's feeling down. Let me just scroll that. Yep, feeling down, and she's depressed. She's weak. She's in pain. She has very little pleasure in doing things. She's got wheezing and coughing. She's got abscess under the axilla, and she's got lots of pain, generalized pain. I'll give you a minute here to look at the past history. It can be... I still remember, you know, in even years of doing this, when I saw her past history here, and later on, you're going to see her medication, it takes your breath away. I'll let you scroll down some of that. Again, focusing on the social history, you know, who's taking care of Betty? You know, where's her husband? Husband is a truck driver. He's away. There's a daughter that lives with Betty, but she's got mood issues. Son is incarcerated for his fourth DUI, and the daughter is abusive verbally, but does help out with picking up pills and so on. Okay. Again, going over the review system, I will highlight a couple of things. She's got cough and wheeze. She sleeps in a recliner. She gets short of breath when she's up. Her sugars are...look at that. It goes from 40 to 400. She's not on any diet. Most of her sugars are in the 300 range. She's got pain, pain, pain, pain everywhere. Her legs are swollen and discolored, and she's got a swollen lump in the axilla. She's got numbness in her feet, difficulty getting up on the chair, and she's depressed. And looking at her medication list, just again, remember I said the average number of medications our patients take is 17. I don't know. I haven't counted it here, but I think it's more than 17. Right. You know, one of the characteristics or one of the traits that I think that makes a good house call provider is character and actually it's composure. So when you look at Betty, when I saw Betty, when I saw the medication list, when I saw the medication list and the problem list, and when I walked into the basement and the carpet was sticky, right, every step is like, oh, dear, what am I stepping in? You need a certain degree of composure to execute your care plan, because Betty needs your care. You can do, again, there are some screening questions here that you can think about. Let me just take one minute here. And one thing I want to highlight is just the nutrition. You know, the kitchen is very messy, dirty dishes, ants on the counter. Okay. And we do what's called a refrigerator biopsy. With permission, you go and open the fridge. She's got regular sodas, not diet, no fresh fruits, nothing green, nothing yellow, nothing red. It's just that brown color, right? And the freezer frozen dinners, ice cream and pizza. Remember her sugars are 300. Okay. And then you can go down through this social determinant of health here. And then the physical exam. Maybe I'll pause here before we move on to the third case. As you look at Ralph and Betty, what are some initial reactions? Raise your hand. Put it in the chat. A lot of help. A lot of education. Call the social worker. Yes. Absolutely. Absolutely. Any other initial plan for Ralph and for Betty? Complex. Polypharmacy. Where to start? Yeah. Polypharmacy and deprescribe. Oh, my goodness. Absolutely. Especially Betty. I mean, Ralph to a certain extent as well. I think we can optimize his medications. Maybe for him he needs actually a higher dose of perhaps certain medications. Betty, oh, for heavens, Betty needs less pills. I think I may be hurting Betty by having her on so many pills. What will your frequency initially? Oh, that's a great question. So especially for Betty, I think I have two reactions. One reaction is I don't want to see Betty any time soon because it's just such a difficult place to deliver care, right? Being perfectly honest. But then the other side of me that says you need to see her next week. You need to see her weekly for three or four weeks. So regarding the front loading question, I front loaded Betty specifically and I saw her weekly for I can't remember, three to four weeks or five weeks because there were just so many things I had to unpack. Going back to Ralph regarding the front loading question maybe for Ralph and this goes back to what Brianna talked about process. Think about what is your process for your transitional care patient? There's a nailer model which ACCI talked about in one of our offerings in I think it's advanced applications where it talks about the nailer model for transitional care. Basically it's a weekly visit for four weeks and then monthly visits for two additional weeks and then to be determined after that, okay? Again, you have to think about what your workforce is able to do, what the patient's needs are and what model you may want to think about in terms of somebody like Betty, just horrendously complex and then somebody like Ralph who's post-hospital, who's a frequent flyer. What is your intervention going to look like? And you didn't do it alone, right, Paul? I mean, I remember you called in home health, social work, a lot of support right away for these patients. Oh, absolutely. Remember what I said before, I am only a doctor. I can't fix your money situation for Ralph, right? I cannot fix the walking. Well, maybe I'll be able to help a little bit, but I need help with Betty, with physical therapy, with diet, with medication management and so on. I need a team. I cannot do this alone. As medicine changes, medicine changes as healthcare is putting more, you know, we've been talking about value-based care, right? The burden and the risk is going to be shifted more and more onto whom? Onto us, onto the practice. To do this well, you're going to need a team. So if you learn nothing else from Ralph and Betty so far, just remember that they're horribly complex. I'm only a doctor. There's only so much I can do. I need expertise and input from other people, whether it's within your team or your contract or home health or somebody else to help co-manage these folks. Thank you, Brenna. So there's a new concern. Betty, there's a dark area on her legs and she's worried that she's serious, that this is something serious, that this is gangrene, that she's going to lose her legs. So your plan for the visit today, follow up on your chronic conditions and medication management, check where the retina, the discoloration on the leg. Talk about your goals of care and then reassess the safety concern. Remember, she can't get out of the basement. What happened? There's a fire. Does she have a smoke detector and so on? Life alert, etc. The next patient we'll meet is MJ. He's a new patient. He was discharged from the hospital yesterday for abdominal pain. This is our first appointment with MJ. You're seeing him at home. You can see his past history. He's got a history of CBA with a right hemiparesis, ACC, Parkinson's, ACC. Keep those in mind. Inguinal hernia that protrudes and he gets frightened and he goes to the emergency room. You can see his past history there. Again, you've got a lot of issues, a lot of coding opportunities. The immunizations there, his social history, he's a retired cook. He lives with a niece, caregiver. Remember to support the caregiver. She works part-time. She has to leave him for periods of time during the day. The wife has advanced dementia. She does not live with them. There's a financial strain because of her condition and where she's living at. Keep scrolling down. Thank you. You can take a quick look at the review of systems here. He's got some urinary frequency. Sugar is, again, all over the place. He's got some tremors. He's got trouble sleeping. There is medication, not nearly as oppressive, if you want to call it that, as Betty's. But maybe there's still some things that we can tweak. We can change. We can modify, eliminate, or prescribe appropriately. I'll just park here for a few seconds here. I want you guys to take a look at the medications. Maybe there are one or two that jumps out at you and say, well, I don't think you should be taking this. Okay. Next slide. Scroll down, Melissa. Thank you. Yep. Again, there's just some screening. We talked about depression screening. Maybe this one will highlight the Tuck test. The Tuck score is not bad, but he's got a slow and tentative pace. It looks like he's got some feature that's consistent with his Parkinson's disease, right, with the little arm swing, the shuffling, the end block turning, and so on. He wasn't using his walker properly. Maybe there's an educational opportunity there. Maybe I'll just highlight one more. We talked about the PH2Q and 9 as before. There are different cognitive screening for our health system. For my EHR, we use the mini-cog, and that's basically a three-item recall and a clock drawing. As you think about building out your service line and building into your EHR, what makes sense for you and your providers? We have not had a chance to talk about spiritual things. Maybe I will highlight here. He's an Orthodox Christian, and it's very important to him, but he's not been able to attend a church service. He was in the hospital, unfortunately, unable to celebrate Greek Easter because he was hospitalized. Could that be causing his mood to be down? Is there an intervention that we can do for him there? Scroll down. Again, these are just screening. Take a look at those when you have some time. There are his vitals. For our practice, if somebody's at a fall risk or if somebody's fallen, we almost always do an orthostatic blood pressure sitting, standing, especially with him having Parkinson's disease and Parkinson's medications. Parkinson's can have autonomic insufficiency, and the medication can cause orthostatic hypotension. Keep that in mind. Again, there's that medication piece. You can see that he's got some of the findings that's consistent with Parkinson's disease. His legs are not swollen. Scroll down. You can see that goals of care. He prefers not being re-hospitalized. So again, you know, take a minute there to review his case. And now that you've got, now that you've gotten acquainted with MJ, Betty and Ralph, think about what you will need for your visit. What supplies you may need, okay? Remember, Brianna talked about planning your day, and as clinicians, as house call providers, I think it's really important for you to, like I said, you know, I do a lot of pre-charting, review, pre-ordering, so that I can stay focused with my patient and engaged, rather than staring down at the laptop. And we do have a list, and Melissa, learners can access this list, correct? We gave, yeah, this list is not like you have to have all of this, but just something to consider. Remember, if you don't have any equipment, you just can't go to the next exam room. You have to drive all the way back or make another visit. That will be unfortunate. So, Melissa, are learners able to access this list? Yeah, this is in the HCCI Learning Hub. Beautiful, okay. Yeah, think about what you might need for the visit. So, any questions so far? Next slide, please. Okay, we are going to go on a simulated house call. We're gonna have some time with each of the patients. We gave you kind of the background sketch of these individuals. And as we go through this activity, there's gonna be some decision points where you're gonna have to choose A or B or C. And I want us to have an opportunity to engage and talk about what do you wanna do first, what made you wanna do that, and what are some of the potential consequences of your decision, all right? And then we're gonna debrief after we're done with this to talk about what is your care plan? And then Brianna's gonna talk about how each visit might be coded optimally. Yeah, and so just one change, I think for time, because we're running a little bit behind, we're gonna just have 20 minutes with each patient. I have to do a little magic here to switch to a different slide set, so bear with me. Okay. All right. So we're heading to Ralph's house first. Yep, we're heading, we're driving over to Ralph's home. And we gave you some example pictures. Remember, you know, the house call visit begins even before you enter the patient's room. Home. All right. Take a look at the surroundings. Look at his house. Look at his access. And then just get some clues from the pictures here. We got cigarettes. We got low pulse ox. We got pizza. Okay. These are all things as you maybe walk through the house or walk by a certain room. Take in all the information that you can. Okay. Next. Oh, you walk in. There's an urgent situation which happens. Reggie meets you at the door. He's a little panicky. He can't talk. He's sitting in a TV room. He's short of breath. Pulse ox is 78. Hey, it's been going on for a couple hours. And he called us off the office and we were on our way. He's sitting in his favorite chair. He looks short of breath. He gives you, you know, a wave, thumbs up when he sees you. Next. Here's your first decision point. How many would call 911? How many would just say, I'm going to stick around for a little bit and check out Ralph and his situation? Yeah. Most people want to, most people want to do the scenario too. Does that, remember his pulse? He's a full code. Does that, I don't know, bother you or is that, is bother the right word? Does that affect your decision? Most of us are saying assess, assess, assess. His pulse ox is 78. He's a full resuscitation patient. You're okay still with hanging around? Yes? Most of us? I mean, he looked okay. He waved at me. Right. Yeah. But it does bother me. Yeah. There's, there's that little voice back there. Like, well, maybe I should call 911. Right. Yeah. All right. For the sake of time, Melissa, no more delay. I think, so we're going to assess the Ralph's situation. You're going to take a little time. What do you want to assess first? All right. Here's, here's six choices. You know, what do you, what do you want to do first? Maybe we should say for this, again, for the sake of time, the top two or three things you want to look. Oxygen. Everybody's going for oxygen. Oxygen. Nobody's voting for a depression screening. So he's, he's got his nasal cannula on. His concentrator is at three liters. Okay. You check that. What, what's next? Oxygen and meds. What are your next steps? O2 and meds. It's tubing kink. There you go. Caught in the door. Is it kinked? Great. Remember being a house call provider, we have so many opportunities to intervene. So many more things that we can see and maybe fix than an office doc or ER doc and so on. Check if the concentrator is plugged in and if it's working, if it's not working, maybe get some portable tanks and check his pulse ox to see if it improves. If he doesn't improve, maybe it's time to call 911, right? You're spending some time assessing Ralph and, and, and trying to troubleshoot. So after you fix his concentrator, it, maybe it wasn't plugged in. His, his oxygen rises to 92. He's feeling better. And then you look around and, and remember the pictures that we saw of the electrical outlets and one was kind of, kind of like burnt. Maybe you need to call, depending on what you find, maybe you need to call the oxygen company. Maybe you need to contact a power company to resume services or to have electrician come and work on the house. Maybe there's a short in the house somewhere. What else? Anything else? Any other comments? Okay. Okay. All right. So, so you got the oxygen going. What's the next, next thing you want to, to, to assess with Ralph? I think somebody said, let me scroll up here. Somebody said medic. I think somebody said medications. Assess, assess, assess medications and caregiver. All right. Let's have some more other people chime in here. Caregiver goals of care, lots of directions, right? Lots of direction to go with, with somebody like Ralph or Betty and so on. So should we review a systems? Okay. Yeah. Okay. Fever, sputum. There you go. So I think we can do medic, medications. All right. Assess medication, diet, tobacco. His weight is up five pounds. How's his diet been? With my brother dying, went to the funeral, went down to Georgia, stayed and stay to help put things in order. She's been the one who's been shopping for me and knows how to get healthy, low salt food. I've been eating my Campbell's soup. That's good nutrition, right? How do you interpret this? Good nutrition and Campbell's soup. Well, that might be what the commercial tells you. Campbell is what I'm good. Or I think that's what the, how the tagline goes. But is it really healthy? You know, what can we do as providers here in terms of intervention or education? Think about what you might, you know, his weight is up. He has a history of what I think is half ref and his EF is 40%. Okay. Education. Yeah. Maybe what about, is this short of breath, COPD? It might be, it might be just lack of oxygen or is it maybe heart failure? Remember what I talked about, about multi-complexity, right? Keep that in mind. These patients can be difficult, tricky to diagnose. You know, they're short of breath. They have CKD, CHF and COPD, you know, and their legs are swollen. You know, what, what, what is, you know, what is causing the problem here? So be very good at being a detective, getting a history and doing a, an exquisite exam as best as you can at home. And also just to put in a plug, I think for their advanced application class, we're going to be teaching and demonstrating POCUS or point of care ultrasound. You can Google POCUS, P-O-C-U-S. And having a device like that may be able to help you assess a volume in a patient like Ralph. Okay. Has he been smoking more? Yes. He's been smoking. On and off, right? So what are some potential next steps? Remember we talked about a refrigerator biopsy, go over his medications. Maybe he needs more water pill, decongestant, right? Maybe he is, carbadolol needs to be increased to a more, a goal directive level, maybe a 25 milligram twice a day instead of the relatively small dose of three, 3.125. And, and he's, he's started smoking again. Somebody was very astute in picking that up. You know what, he's got oxygen at home and he's smoking. Oh dear. You know, anything else, any other comments? There were some comments in the chat about, you know, maybe meal assistance and education about the heart failure about the ibuprofen potentially triggering. And he's also on two beta blockers. Yeah, there you go. So again, go back to, to the, to, to the list, to his medications. Think about what he, what conditions he has and what medications he should be on. Remember having a good working knowledge, a HFREF, you know, he should be on these medications. Okay. His AFib, he should be on these medications. If he's got COPD, we talked about, you know, LAMA, LABA, a rescue kind of a inhaler, maybe inhale steroids or not. So, hold on. Sorry, I lost my train of thought, but, but having, having, knowing what disease he has and think about what medications he should be on can help you appropriately prescribe or escalate medication and deprescribe. So absolutely, you're right. He's on metoprolol in the bag. Is he taking it or is he on Carvedo or is he taking both? Yeah. So, and then he's on ibuprofen, right? But he's also on warfarin. That's, that can't be a good combination. So great points. Melissa, how are we doing on time? Do we need to move on? We have time to do one more thing for Ralph and then move on. Okay. Thank you for your comments about getting education and meal support. And all of you guys know this already. It, it does take a village to take care of our patients. And I think there was a, about goals of care, right? So it says goals there. So maybe we can talk about, so when you look at this, what is, how would you interpret it? Any concerns given his history of recurrent hospitalizations and he's on three liters of oxygen and he wants to be resuscitated with full, full treatment, including being intubated and so on. What are your thoughts initially, how you may want to review this with Ralph, discuss this with Ralph and Reggie? Yeah, that's beautiful. Start by asking about quality of life, what's important to him. Does he know his prognosis? Yeah, let's start with basic things he may not understand at all. Yeah, he doesn't know where his disease process is. These are, I so appreciate the comments. And I'm trying to tell myself, I'm trying to tell myself not to make statements rather to ask questions because asking questions will give me, it'll help me find an entry point for the discussion rather than me saying, you need to do this, you need to do that. So as providers, we're very used to telling patients what to do, but I think I'd need to constantly unlearn that and try to ask questions to understand the patient and maybe the question underneath the question or the patient behind the question, perhaps. He may not understand where his disease process is. And again, with MD-Calc, there is a prognostication, the bold index for COPD does B-O, put that in there as B-O, just spell it B-O-D-E for prognostication for those patients with COPD. Yeah, the follow-up to this item too was about also assessing decision-making capacity. Yeah, yeah. Again, I think Brianna talked about, or maybe it was Dr. Suri that talked about, there's a template, there's a coding opportunity for cognitive assessment. Assessing the patient's ability to make decisions whether they have dementia or maybe some other illness that may be affecting their cognition. So I do, I think I will, I do those cognitive testing when there's a concern about there's a legal matter that needs the patient's input and whatnot. And I need to be sure that the patient, even though maybe he has a little bit of memory issue, that he is still having the capacity to make those medical decisions. Any other comments? So I wanna give you a couple of minutes here to fill out your care plan for Ralph. I'm gonna do the same for Betty and also for MJ. So think about maybe the top three things that you wanna do for Ralph. And there is a worksheet in the hub. You can use a care plan worksheet, but you don't have to use that either. Alright, so welcome to Betty's house. Again, there's some pictures. There were mattresses on the front lawn when I saw Betty, so that it's kind of messy on the outside, it might be messy on the inside. The refrigerator biopsy, the polypharmacy, the pictures there, and there's the walker, there's the not so happy daughter, right? That's there. Again, we put up some review of systems and examination. I'll give you a minute or so to look through them. And then we're going to just give you a minute here. And then we're going to go over and do the flip charts again. Okay, here we go. We got more choices this time. I think we have six with Ralph. We have more. Remember when I said I walked into Betty's house and saw the mess, it's like, whoa, it takes your breath away. What do you want to tackle first? Her chief complaint, her neglect, her goals of care, nutrition. We can't tackle all of this at one visit or even two visits. What are the top one or two or three things you want to go after first? Kate says tie between environmental safety and abuse and neglect. Okay, keep going. I would like to hear other people's comments. Patient's primary concern is safety. patient's concern. Yeah. You know, with patients like Betty, there's so many, there's so many ways we can go with this. I think it's really important to, and Kate, I totally get you, you know, without a safe environment and the risk of neglect and abuse, she's not in a good place. Having said that, for Betty, I think I need to have, I need to establish a relationship of trust, of cooperation. And I'm concerned if I don't address her concern, her chief complaint, that she may feel like I'm not listening, even though I am, and I'm worried about her environment and her safety and all of that. But I want to make that connection. I want to build that trust with her, knowing that she's, yeah, I hear you. You got, you know, this swelling under your armpit or the discoloration in your legs. I get it. I'm here to help. Yeah, she's got a ton of other issues, but maybe this first step is that we need to shake hands. We need to come to an agreement. So let's flip to the patient's primary concern. So I asked, you know, what, what bothers you, Betty? And her reply, my legs, they're black. Do I have gangrene? Of course, there's never just one chief complaint, all my bones are aching. I have a terrible headache. My head hurts so bad. My vision is blurry. Do you think they're related? Am I going to die? As you think about, yeah, what priorities does Betty expressed on these questions? And how would you address that last kind of the existential question, am I going to die? How would you address that? You can unmute if it's easier just to speak because there are a lot of nuanced answers here, right? So if you wanna go ahead and unmute or get yourself on camera even, we're finishing our day here, we're almost done. So this is Tasha, I think that responding to the question of, am I going to die? I was getting ready to type in compassionate humor. I mean, that's obviously something you have to kind of read how you feel like they would respond to that, but kind of like at some point we're all gonna die, Betty, but hopefully you're not gonna die anytime soon. And I'm here to help figure out how to help you feel better or something along those lines. Thank you, I was gonna say, what did you mean by compassionate humor? You explained that, thank you. It's always tricky, right? Sometimes the jokes can be really, I can really fall flat on the jokes or be a little not inappropriate in a sense that it's just not helpful and I'm not a good jokester. But those of you more gifted in that, that's wonderful. Any others regarding her last question, am I going to die? I think it's important to acknowledge that she's very worried and ask her what's worrying her the most. You know why? That's a big statement for her to say, and she could lead you down the path of major depression or she could lead you down the path of, I had a friend who had an amputation and lost her leg and died in the hospital. So I think, just asking her to tell you a bit more about what's prompting her to say that today of all days is really important and would not only help you build the rapport, but prioritize the rest of your visit. Is it gonna be a mental health visit or is it gonna be about her cellulitis, her peripheral vascular disease and her uncontrolled diabetes, so. Yep, yeah, remember to ask the questions rather than making statements. You know, for me, I would have said, you're not gonna die, you know, not today. That would have been a statement, but you're absolutely right asking that question. You know, what makes you think you're gonna die? You know, what are your concerns? And then again, finding that point of entry, right? So I think for many of us, we will look at her legs, right? And maybe do a neurologic exam because she's got this terrible headache and maybe reassure her based on your exam. Okay, so we got the chief complaint there. What would people would like to do next? Thank you. Anybody Goals of care, yep. What else? Do an exam, does she have an active infection? Sure. Like why are the legs black? There you go, yeah. I'll click that. Physical exam, you can refer her. Do we have that picture board there, a physical exam? She's got chronic, her legs, we're gonna focus on her legs, right? She's got these chronic venous stasis changes. She's got these rough brown color skin with plaques scattered on her legs down and they're a little sore to touch and they're dry. That doesn't sound like gangrene, right? So you might be her best buddy today and building that, somebody mentioned rapport, right? And say, Betty, I don't think it's gangrene. I think it might be X, Y, Z, all right? And providing her that reassurance. Remember that existential question that she asked, am I going to die? And maybe you have just provided her with such relief. You know, does not have gangrene, her legs are black, just poor hygiene. And then just along with chronic stasis dermatitis, it's got no sores, it's not infected. The previously noted the abscess in the armpit has healed up and her neurologic exam is unchanged. Okay, Melissa, we have a prompt for this. Yeah, just, yeah, how would you address these issues? Yeah, I think providing a lot of reassurance for Betty at this stage as the first step in building that relationship, which is so important. We all know we can't fix Betty in a day, well, in one visit, in two visits, in multiple visits. It's gonna take time, it's gonna take trust and relationship and all of that to get Betty the care that she really, she desperately needs. I think we have time for one more for Betty. Okay, one more. I think it was goals of care. Let's pick that one. All right. Goals of care. So I say, I wanna work with you and your family to help you getting better. You have a lot of medical problems and I know from what you have told me, you're not feeling well. What are some things that you would like to do or see changed that we can work towards together? This partnership, this relationship. I would like to be able to get back upstairs so I can cook and visit my friends. I wanna be in less pain. You have to do something about the swelling and discoloration of my legs. Can you just give me more water pills? My neck hurts so much, it's hard for me to get comfortable. Okay. So what are her goals? What is she telling you? it's almost the four Ms. Yeah, she wants to be more functional. You know, the M is medication, right? We got mobility. She wants to be more functional. She almost gave us the script for four Ms. The goals of being more mobile, the medications, what matters most to her, she's telling us she wants to cook, right? socializing. Yeah. So she's given you. So what you build the relationship, you address the the legs thing. And now she's giving you the recipe, hopefully for success. In the future, right? She has given you 1234 things that you are three things that you would like to have you work on in the days ahead. To get her upstairs to socialize, to be more functional, visit with friends to cook, and so on. Right. Do we have time, Melissa, or should we move on to the final? If, if, if, because Betty's a complex case, if you want to do one more, we could do one more. All right, one more. Do we want to go back to what the other person, someone said earlier about the high, you know, assessing safety and- Oh yeah, yeah, let's do that one. Thank you, Brianna. Thank you, Brianna. Environmental safety. Yep. Hang on, oops. Let's do safety, yep. So yeah, the provider asks, do you have a smoke detector, carbon monoxide detector? What will you do in case of an emergency? Like if there's a fire, do you have an escape plan? Yeah. I think we have both of those. I think we have both of those in this house, but I don't know if they work. Great. That's my husband's job. Remember, he's not home much of the time, right? What would I do in an emergency? I will call 911 and they will have to get me out of the basement, I guess. There's no other way for me to get out. Betty's house is so cluttered, just dirty dishes and sink and ants. What are your potential next steps to help with like a safer environment? Comments. Again, feel free to unmute. We have about half an hour left. Let your voice be heard. You know? Maybe get somebody in the house, come and clean or pest control, something like that. There we go. Let me just go down and get... Great. Can she relocate to an upstairs room? That's a good suggestion, right? Is facility placement an option? You know, for Betty, I don't think she wanted to go and I don't think they could afford it, but that's certainly something to discuss with Betty as part of both your environmental safety concerns and also your goals of care. Would you call her husband? Say, hey, I'm worried about Betty. Do you think that's gonna help or is that just gonna be kind of a, the husband is gonna find you a nuisance for calling her, hey, fix the smoke detector, buddy. Yeah. What would people do? So I think calling the husband's kind of like overstepping. You got HIPAA and all that kind of stuff in there as well. But also, I mean, there was that picture of the angry daughter. So like, what is Betty's actual living situation? Like whose house is it? And is the daughter there all the time or just sometimes? How does she play in? And I also think that, you know, your prompt here about what issues are safety concern versus preference is really important because clutter, dirty dishes, ants, you know, I wouldn't wanna live like that, but is it a real safety issue? That's, you know, there's a line there, I guess. Yep. No, I don't know the, well, I think the main safety issue for me when I was there seeing Betty is her, I don't know how much does she weigh? She's like 400, I think she's like 400 pounds. I don't know what it said in the history. The real concern for me was what to do in case of an emergency, if there was a fire in the house. Of course, I have a safety concern about the dirty dishes, like, you know, how clean is the food and so on. But at least for me, the very first impression was how are you gonna get out of the house, you know, in case there was anything urgent. Other comments? Oh, your relationship with the daughter. It's Betty's and her husband's home, to the best of my recollection. The daughter, I don't know, I don't think she worked. She's upstairs. It's kind of weird relationship-wise. So Betty would yell up from her basement to the daughter who was on, the split level would be on the second floor, I guess. She would yell up and the daughter would not respond. And then she would text her on her phone and the daughter would come down briefly, like toss me her meds and then she would leave. We had a hospice patient like this not too long ago. Yeah, so the daughter was disengaged. I mean, she did pick up her medicines for her mom, I suppose, but in terms of helping mom in any way, boy, she was definitely not there. All right, take a minute there. Think about Betty. Think about your approach. Yeah, like Brianna said about, there's no one size fits all. I can't say that this is exactly the approach you need to take with Betty, because there could be so many points of entry for her in terms of intervention. Yeah, I think that's it for this session. I'm going to go ahead and close out the meeting. Thank you. Okay, our final stop today, and then we're going to go home for dinner. You come to MJ's home, you meet him and his niece, Olivia, the review system you see there. And then again, as you walk in, taking all the clues, you know, as you're walking by, what assist device, where are the medications, what is MJ eating, okay, take it all in because like I said before, we have such an advantage over a office doc or hospital doc, we get to be at the home, we get to see their, their real struggles, and also their joys is not all bad at home. I don't want to make it sound like it's all horrible living at home, right, there's such, our patients have such talents and such histories, whether it's, it's, it's painting, whether it's photography, whether it's the Cubs, right, they're flying the, you know, the W flag for for win, or, oh, I saw this very cute, adorable 90s for 92 year old lady with bad rheumatism or arthritis, but she was knitting, and she taught a knitting class, and they called her, I didn't make this up, they called her the happy hooker, okay. So our patients, it's, it's, we get to see so much of our patients at home, and both their struggles and as well as their joys. All right, let's, right, yeah, here's the review of findings, you see that he's complaining of the dysphagia, the weight loss, the tremors, he's got Parkinson's, arthritis, the sugar is this, remember, he keeps going to the ER with what, bellyache and the concern about that, about this very, this large hernia, right? And Tasha, I love your comment, home-based work allows for discovery rather than reliance on disclosure. Isn't it so fun? You get to be, you get to, you know, it is a privilege to be in the homes of our patient, it truly is, and I absolutely love my job. You get to step inside because every patient, every encounter is just so different, every house is so different, it could be wonderful, beautiful house with all this and that, or it could be a Betty house, right? It is such an amazing place to practice medicine. I can't say that enough. All right, okie-dokie, lots of choices again. Let's pick a top two or three, what would you, what would you address first? I mean, he's got the symptoms, we review his systems about his weakness, his dysphagia, his trouble walking, and then on the objective side, you've got this big hernia, he's got this sugar issue and this historical information that you have about him going to the emergency room a lot because of what? Because of his bellyache, right? So patient concerns, Melissa, you want to try going to patient concerns, okay. So I asked MJ, what would you like me, what would you like to make sure we talk about today? I haven't seen my cardiologist for two years, they have my blood drawn here at home for my warfarin test. Now they say, I don't, if I don't come in for an appointment, they will stop refilling my heart medication. And I can't stand checking my blood sugars four times a day. I want to go out to church, but I'm unsteady and it's hard on my niece, remember, I think she works part time, if I remember correctly. Yeah, patients request for ongoing specialty care, you know, how do you address this for your home limited patients? Before I get to that, sometimes there's this disconnect between what I want to do for my MJ and what MJ wants, right? Sometimes I feel like we're on two completely different planets. Like I want to talk about your hernia. I want to educate you on that. I want to keep you out of the emergency room. That's what, that's my mission. That's what I want to do today. And MJ comes out of the left field and tell me about his cardiologist, I'm like, what? So sometimes it's hard for me to say, hey, you know what, Paul, let's talk about what's important for him. And maybe your agenda could be the second visit, maybe next week or something and talk about what's really concerning for him. So I was going to say, getting back to the cardiologist and specialist and so on. And I talked about this earlier when I discussed the multi-complexity section about building that relationship with a cardiologist or whatnot so that you can, again, two-way get referrals possibly and also get the care that your patients need. And then on the flip side, another flip side, a follow-up would be, you know, being comfortable taking over some of the management and assuming the role of a, you know, a semi-cardiologist, if you will, and taking care of patients in the comforts of their home and being comfortable managing their heart failure meds and so on. So call the cardiologist, absolutely. Having that relationship. Warfarin testing. Can you do the Warfarin test at home? Are you comfortable managing Warfarin, the INRs, okay? Do you have a protocol for managing INRs? We talked about process earlier, about less touches. Do you have a flowchart for your nurse? If your INR is this, your weekly dose is this, I'm going to increase your weekly dose by this and then recheck INR either in one week or more acutely, like two to three days. Or if it's stable, like four weeks, okay? Do you have the comfort level of doing that? Do you have a protocol for doing that? What about testing your sugar four times a day? Oh my. Yeah, does he need to do that? You know, it's, it's four times a day. And that's pretty intense, right? Um, this goes back to the, you know, the goals of care conversation. What are your goals? Maybe we don't need to test it so much, uh, or so often. Um, what about, uh, what about CGMs or continuous glucose monitoring? Are you comfortable? Um, um, whether you're talking about a freestyle Libre or, uh, or, or Dexcom, uh, uh, device, uh, or do you need an in-service with your team? Um, that could cut down the frequency of testing, right? Uh, if there's concerned about blood sugar, or you might just reduce the blood sugar testing altogether like twice a day or once a day, uh, depending on the, uh, the patient's goals of care. Other comments, what about getting to church? What are some ways that perhaps we can intervene? Although I'm, you know, I'm just a doctor, right? Creative solutions, put them in the chat box. Physical therapy, absolutely. Wheelchair. Transportation. Transport service. Yeah. Reach out to clergy. There are volunteers. Great ideas. Clergy visit. Yeah. You know, I've done in the past, you know, obviously with permission, I would say, hey, MJ, is it okay that I call your pastor? Would it be okay? And explain to Sorry, and explain to the clergy that, hey, you know, you have one of your parishioners here who really could benefit from some intervention. And also from a process side. Do you have transportation information that you can provide for the patients and and their, their caregivers, in case they needed to get somewhere to increase their sociability and so on, and volunteers. Absolutely. Great. Thanks. All right, one more. What else. Um, did somebody say something else earlier to do to see patient concern. I think we only saw patient concerns but what where should we go next. Where should we go next. Where should we go next. Visit. So you say to Olivia, you've called 911 on several occasions. What were your reasons? And Olivia says, he has a hernia that sometimes bulges out. I was told that he could die if it's not put back in. There's that, there's that distress again, right? There's what the Betty say, am I going to die? And Olivia is concerned that MJ is going to die. So what are some things you can do for MJ to help with these trips to the ER? Domino binder. Yep. Absolutely. Teach. There you go. You guys are hitting it. Absolutely. Yeah. It's great. That must be scary. Acknowledging Olivia's concern, right? Acknowledging that. And let's explore ways to deal with that. This is where you, you educate. I see all the comments about avoiding constipation about, you know, this is how you reduce a hernia. You know, this is a binder you can, you can use and so forth. Our presence and our knowledge don't ever underestimate that the power of your presence and your ability to make, you know, to us, this is pretty simple, like, you know, good grief, you know, what's, what's this, but for them, it could be very scary. So we could be very, we can be so helpful to our patients and their loved ones regarding, you know, helping them navigate, understand that, you know, we see hernias not infrequently. The majority of the patients with hernias don't die. And this is a way that you can manage at home if it ever came to be an issue again. Great. Great comments. Appreciate it. Do you want to do one more or do we have time? So we have till 445 to do our debrief and the coding. So I think we have. All right. One more. There was a comment earlier about the prescriptions being in Greek and being concerned about polypharmacy. So I don't know if we want to thank you. Thank you for that. Let's pick polypharmacy. And that's a great question. Not a question, a great comment about language and barriers. I think in DuPage County, where I practice, I have what 50 I don't know, I can Google that, like 40 different ethnic groups. Ethnic groups. And they, well, you get the idea. Not everybody speaks English. And we use a translator service. And that's something you may want to consider as you engage with your patients. And you all know this, especially when you talk about, you know, end of life decisions and so on. Not to use family members, because it's just not recommended. Having said that, MJ's on multiple medications. You review his medication list, over-the-counter meds. You do the reconciliation, justification, and so on. You ask MJ a little bit about how they organize his medication and make sure he, you know, he stays on schedule. Yeah. Yeah. And this activity doesn't address the need for translation. We do have that in a different thing. But it does beg the question about polypharmacy. Yeah. So how would you approach his polypharmacy on first visit? Let's just look at the comments here. Brianna, you talked about capturing if they need an interpreter on the intake documentation. Yep. Absolutely. That's part of the intake process. Right. So your providers will be alerted to what they may face in terms of barriers when they enter the home. So that you will not be like a complete surprise that the patient may not be very eloquent with English. How would you approach MJ's polypharmacy? Melissa, is it possible to go back to his medication list since we're talking about that? Yeah, absolutely. Yeah, what can we do about his medications here. People can fill in comments, please. We just got a couple minutes left before we wrap up our session for today. Okay, I like that. Just start with reconciliation. If he's taking a prescribed, it would not focus on deep prescribing first visit unless major interaction side effect. Yes. You know, we start with something simple like, hey, you know, we're going to leave the medication as they are, but I'm going to come back. We're going to talk, we're going to talk about your medication to the future time. You know, one thing it does stand out to me, right? He's on, what is it? He's on aspirin. He's on warfarin and he's on, he's got a PR and ibuprofen. That's again, probably not, not the best idea. Anyone else? What was I going to say? Oh, be careful with, remember he was orthostatic and his blood pressures, remember he's already got Parkinson's, he's already got Parkinson's disease that in and of itself can cause orthostasis. He's on a carbidopa levodopa that can cause orthostasis. And there's one more medication, right? The Tamsulosin that can cause orthostatic hypotension. And plus he's on diuretics and so on and so forth that you might want to keep that in mind. You may want to talk about a, the abdominal binder might be helpful in other ways, like keeping his blood pressure up or you might need compression devices in his legs to help sustain his blood pressure or, you know, hate to add more pills, but you know, if you really need all of them, maybe using medication like Middledren to sustain his BP might be indicated. Age, goals of care, A1C should be considered in the reduction. Absolutely. Absolutely. And just to, I mean, there's, we have a session on deprescribing for ACCI, but just a quick comment about deprescribing. There's a little bit of art to this, but there's a lot of relationship in this, in the whole idea of deprescribing. No, I'm not trying to hurt you. No, I will, I will not abandon you. Yes, I'm here to answer your question about deprescribing. And yes, we're going to, we're going to go slow and deprescribe your, your medications and reach out to me if there's any concern as we deprescribe your pills. Yeah. All right. Now, take a minute to fill out your care plan for MJ. And then Brianna is going to quiz you all on, on how would you code for each of these visits? It doesn't have to be a quiz. We'll just talk high level, kind of about, about the cases I'll, I'll kind of walk you through and then welcome your comments in the chat, or if we want to unmute. In your HCCI Learning Hub, you do have a worksheet called the HCCI Super Bill. You could look at that. Some of these more advanced coding opportunities we talked about are summarized in that advanced coding handout. And then there's also an E&M guide, and I can put the, I don't think it's in your materials, but you can download it for free on HCCI's website. So I will put the link for the E&M guide in the chat as well, that's specific to home-based and domiciliary codes. And the Super Bill does have the nursing home, the skilled nursing facility codes on it as well. We didn't talk about those today, or the past two days, but those are available as well. So starting with Ralph, if we think back to his patient case that you have in your materials, you know, this was a post-hospital visit for Ralph. He had three unstable, you know, poorly controlled or worsening chronic conditions, you know, the smoking. We talked about goals of care. As far as what you would code for the actual visit, any thoughts that anyone wants to share there? You can put it in the chat. Ah, yeah, those might be going to some hospice codes. Again, I was talking, thank you for clarifying, so like fee-for-service wise, if we're talking about the house call E&M codes, your option would be kind of that transitional care management visit, that 99495 or the 99496. Those could be, you know, a starting place. Those will pay more if we're talking fee-for-service specifically than the typical house call codes. The difference between the two is the 99495, you have to see the patient within 14 calendar days of discharge from their hospital admission. The 99496, you would have to see them within 7 calendar days of discharge, and you would also have to support high medical decision-making complexity for the higher-level TCM versus moderate for the mid-level. But if you're in fee-for-service, $281 is the reimbursement for the 99496, so that might be an option. If you counseled him on smoking sensation, that would be, you know, another potential fee-for-service option if you spent 4 or more minutes doing that, the 99406. And then there was comments, it wasn't filled out completely from like a billing standpoint, but there was advanced care planning, so maybe it wasn't that visit, but at some visit, if you had that extensive advanced care planning conversation with Ralph, that might be another option. Good question. So, can you do TCM and advanced care planning during the same visit? Yes, you can. As long as, you know, the advanced care planning in the fee-for-service world is a time-based service, so you would have to spend at least 16 minutes minimum just on the advanced care planning discussion. So, TCM is not a time-based service, so you would have all of your documentation for your TCM visit, and then usually that's, I recommend like a separate area in the template or a smart phrase specifically for your advanced care planning documentation, and you would want total time, a summary of that discussion, you know, you have to customize that to kind of warrant that that time was really spent and what the patient's preferences really were. But yes, those could be separately paid together, would need modifier 25 for that as well. All right, so let's think about Betty. In the case in your workbook, Betty was a new patient, so remember we talked about having to see her more frequently, but this was your very first visit with her. You know, she had a lot of concerns, we know that. My thought process here was, do we think we spent a lot of time with Betty? We probably were there for a pretty long time, even if we decided to come back to address multiple things. So, I might think about time-based billing here. You know, new patient, the 99345, the high-level new patient visit would be a 75-minute visit if we were billing the total encounter on time, and that's when I would need that time statement that says, I spent 75 minutes face-to-face with the patient and or caregiver, 50 greater than 50 percent was dominated by counseling and coordination of care, and we focused on her, you know, depression, we're going to get a social worker involved, talked about some coordination of care efforts in trying to help with, you know, her hygiene and managing her safety at home, or, you know, you want to customize that statement always. So, time-based billing could have been an option for her. If you came back and had to see her for a follow-up visit and you were there for 90 minutes, then, you know, you could do 99350 plus 99354 for prolonged services face-to-face for those extended time visits. That resource that I put in the chat has all of those time references. Again, that will be changing next year, so just a reminder to stay up-to-date on the 2023 guidelines that will be coming out, but from a fee-for-service standpoint, she might be a good one that we bill on time. Any other thoughts with Buddy? What about MJ? So, MJ was a new patient. This was your first visit, but he was also a post-hospital visit. We know he had a lot of concerns as well, Parkinson's, what else was there? Talked about some goals of care planning about avoiding hospital or ER trips with Olivia as well. You do have the flexibility or the option to do transitional care management visits whether it's a new or an established patient, it does not matter. What matters with TCM visits is how quickly you saw them post-hospital and the overall level of medical decision making that's supported in your encounter. That's the difference between the two codes. So we might consider a TCM visit for him as well. And then maybe advanced care planning, maybe that 99497 if we had that extended advanced care planning conversation with him as well. Or maybe just the TCM and, you know, it depends on what the circumstances were but you have some options there. With Ralph too, I mean, Ralph had a ton of HCCs. Remember those ICD-10 diagnosis codes, the COPD, pulmonary hypertension, atrial fibrillation, heart failure, lots of things going on with Ralph. So don't forget about the diagnosis coding as well. questions on coding or even just anything we've talked about the last couple days? Comments? You know, I'm just going to remind people that we have, in addition to HCC coding as an online course that you can go back and look at in your bundle, we've got two other coding courses. One is like avoiding negative audit outcomes and the other is more advanced coding. There's lots of cases in there too, so if you are just like completely fried by this time, which I can understand, you can go back to those online courses and, you know, see cases with different patients and different scenarios and kind of test your ability to code on those cases as well. Yeah, that's a great point. The other thing I wanted to mention too is those patient case examples that we reviewed today, if you're looking at, we laid those out very intentionally from like a progress note template standpoint, so that could be a good reference as you're looking at things like that. There's also a sample assessment form that might have been included in your materials that kind of has some guidelines for that. And in addition to, the great thing about this workshop is you all, we tried to make it really easy where we just downloaded all of those resource materials for you in your HCCI Learning Hub associated with this course. But if you have not checked out HCCI's HCC Intelligence Resource Center, I'll put the link in the chat for that too. There is a ton of additional tools and tip sheets that are all free for you to download. They have lots of great information on that, free webinars that they do monthly, so lots of other resources for you all. Quick question, Brianna, or even Melissa, and forgive me because someone may have asked this already, is there a sample template for primary care, like a policy and procedure for the office? Not a policy and procedure, so what we laid out today, I would go back as far as like what processes, I would go back to the slides that we talked about today in the operation session. But if you're looking for like a sample policy and procedure manual, the VA has a really good one. If you look up for the VA for Home-Based Primary Care Policy and Procedure Manual, they have that available. You can find that online and they do have a good example. That's usually where I point people to for policies. All right, great, thank you. And that's also one of the things that we can talk with you about when we have our program development strategy session with you, because it's usually fairly customized, and so if it's a recommendation that you would benefit from having something like that, that we can make some recommendations about putting that together. Okay, thank you. All right, any other questions on coding these visits? All right, I was gonna say, we're gonna let Paul end the day with a patient story like he usually does. Are there any other questions just from the past two days? We do have some additional time if people want to chat. Yeah, we'll be happy to stay on for a couple minutes if people want to chat, to share experiences. Well, yeah, we've got our wrap-up, but I don't know, do you have any key takeaways just from the putting it all together session? Yep, well, you're very welcome. It's great to have all of you. I really like all the comments it makes us faculty. It gives us energy when there's engagement and interaction. I really appreciate that. And remember, even though we're faculty, but we're learning from you guys. We learn from each other. I've said it before, and I'll keep saying it, I don't know everything, and learning from the community. Remember, I talked about wisdom. That is just such an important part of what we do and having that community. So some key takeaways, and I will finish with a patient story. And Melissa, you can bring this home. To do chart prep, remember, pay your attention to spend as much eyeball or eye contact time with your patients. It's really important with your patients at building that relationship. And if you're building for time, as Brianna said, like, Betty was just a mess. Build for time. Document when's your time in and time out. And what did you do? How much of your time was spent on advising and counseling and so on? When there's emergency and it impacts your schedule, work with your office in terms of moving people around. And then giving your office scripting in terms of like, I'm so sorry, but we need to reschedule your visit for next week and so on. Psychosocial, huge issue. It can be overwhelming. Use your team. Use your community resources to help you carry the load. And it's a diet. It's a patient and the caregiver. It's a patient and the caregiver. Take care of the patient. You got to take care of the caregiver. And I think that's a good segue into my story. My staff has heard this before, this story. We've been seeing this patient who's an elderly patient with multi-complexity and dementia who's been declining at home. We tried various interventions trying to get the patient better, improve her condition, but she was just not improving. And we had extensive goals, multiple goals of care conversation with the daughter regarding what to do for mom. And during one of my final visits, we got goals of care planned. We got the advanced directive in place. We optimized her medication the best as we can. And the patient was declining. And the daughter called us urgently needing a visit because mom really wasn't doing well that day. And as I walked through the door with the MA, there were no words exchanged between me and the daughter. She just came up and she gave me an embrace. And she held me for, it felt like a really, really long time. And when she finally let go, she's got tears. I'm tearing up. My MA's tearing up. We're all tearing up. And she said, what will we do without you? In that one minute of interaction with that daughter in her home, and those six words that she said, I got all the value proposition. I got all the elevator speech that I needed. The embrace, I didn't need a patient satisfaction to tell me how we were doing. That embrace told us everything. And her words, pitch the story. You're going to collect stories. Pitch the story like this to whoever wants to hear, to a hospital, to a health system, to a home health agency, to payers. What would these patients do without us, without you all? And if you really want to bring it home and say, if she was your mom, what would she do without us, without home-based care like this? All right. Bring data. We need data. We talked about, you're probably too much information here, but finish it with a story and really bring it home by applying it. If it was your loved one, what would you do? So that's my story. You're going to have stories like that, and I encourage you to build on them and get good at these stories and give a hearing to whoever gives you a chance to share about your passion and your vision for this kind of work. Well, thank you. I'm reading your comments now, and Carl, boy, that's really profound. Let me just tag team on that, and I want to thank our faculty without whom we can't provide this kind of education. I want to thank NPHI for allowing us to work with their members. So I want to thank the learners, all of you, for investing the last two days in this. So just a few housekeeping things. We want to encourage you to please submit your learning plans to us at education at hccinstitute.org and complete your workshop evaluation. You will be receiving an email very soon with instructions for how to do that, how to claim your CME or CE credit, and then we will also have for you in the HCCI Learning Hub recordings from the last two days. So if you had to step out and you missed a session, you really want to go back and look at it. Those recordings are available. Copies of all of the slides are available, and of course, all of the handouts that we've looked at. We want to have you watch your email for instructions regarding scheduling time to meet with our team again, just individually with you and your practice, so that we can start to hear more about your individual needs and develop a plan of recommend some recommendations for that. And then, you know, just a reminder, HCCI exists for one mission to make a home-based care, high-quality home-based medical care accessible to the patients who need it. We know there are not enough providers, and so that workforce development is a huge part of our mission, and we rely on the support of individuals, corporations, and foundations to support our programs. We are so privileged to have been supported over the years by the John A. Hartford Foundation, RRF Foundation for Aging, and many individuals. So, I want to thank you all. We're going to end a few minutes early here, but on a Friday, that's not so bad. And we just hope you have a wonderful weekend, and we look forward to engaging with you again very soon. Quick question. So, Brianna, I had Kim Baxter telling me earlier that she worked with you, gleaned some knowledge from you years ago. Did you start this in preschool? You look like you're 23. That is such a compliment now that I'm like 30, and we're pushing older, but yeah, no, I'm definitely, I feel like I've been doing this a lot longer than I had, and gosh, it's been 10 years now probably, but yeah, I started in my coding world really when I had my first foray into healthcare back in 2012. And yeah, Kim is awesome. It was so great to see some familiar faces, Angela Collins, Kim, Sarah Sharp, you guys are all amazing. So, anyone that I've had the opportunity to work with, but I have tried to impose all of my knowledge on all of you and through HHCI resources, and they have a great team too, and some other young, very energetic people that would be happy to help you, Carl. Well, good. Thank you for that. Thank you much. Brianna, I just have to say, you know, I told Carl today, I have learned so much from you, and you know, in the past, today, this has really been an awesome presentation, you know, and as our organization moves over into the home-based primary care world, this information is just invaluable. So, thank you. Thank you so much, Kim. No, it's honestly been a pleasure, and thank all of you. I mean, I get to do the easy stuff compared to the clinical care that you all are providing. So, thank you. So, thank you for all those great comments. Any other questions before we sign off? All right. Well, thank you, everybody. Have a wonderful weekend. We'll be talking to you soon. Take care. Thank you, everyone. Thanks, everybody. Have a great weekend. Bye, you too. Bye, Sarah. Bye.

HCC coding

risk adjustment

CMS

chronic diseases

Medicare Advantage plans

value-based care models

RAF

diagnosis codes

practice payments

capturing chronic conditions

heart failure

CKD

COPD

medication therapy

follow-up visits