Good afternoon. My name is Melissa Singleton, and I am the Chief Learning Officer for the Home-Centered Care Institute. I want to thank you for being here today for this webinar, The Impact of COVID-19 on Home-Based Primary Care Providers, Practices, and Patients. In this era of social distancing, you may not be aware that in logging into this webinar today, you've come together with around 500 of your colleagues from around the country, all of whom understand that these are not normal times for healthcare, nor our world. We have quite a lot to cover in the next hour, so I want to get straight to it. But first, I want you to know that we have reviewed all of the questions and concerns you submitted when you registered for this webinar. Many of these will be covered in the course of the presentations you're about to hear. If you still have questions, though, we are going to ask you to enter those into the questions box on your control panel, and we will reserve the last 10 minutes of the hour to address them. Recognizing that there may still be more questions than we have time to answer during this hour, I want to assure you that we will have another option for you, a discussion and Q&A thread in a new LinkedIn group that we've set up at HCCI, and I will tell you more about that as we wind down. The slides for today's webinar are available for download in the handout section of your control panel, as well as some additional resources from our presenters at the University of Wisconsin-Madison. Now I'd like to introduce you to our presenters for today, but first I want to express on behalf of HCCI our deep gratitude to these leaders in the field for taking time to put these materials together for us today and for being part of this webinar. They represent four very different institutions across the country, but they recognize that in coming forward to share the guidelines that they've put in place at their programs, that these guidelines are not one-size-fits-all, and they're going to tell you more about that. But house call programs around the country are having to examine their own local context and consider where they are in the stages of this crisis. So our first two presenters are, you know, from one of the, two of the hardest-hit states in this country. We've got Linda DeCherry from, Dr. Linda DeCherry from Mount Sinai at home in New York City, and then Carla, Dr. Carla Parisonotto at the University of California, San Francisco. And after they give their presentations, we'll have presentations by Dr. Steven Barzee and Dr. Melissa Detallo from University of Wisconsin-Madison. And then we have Dr. Paul Chang from Northwestern Medicine. Dr. Chang is also HCCI's Senior Medical and Practice Advisor. And then finally, we have Brianna Plentsner, who is Home Centered Care Institute's Manager of Practice Improvement. And she's prepared to tell you some of the nuances of the Medicare reimbursement changes. So quick overview of what we're doing today, we'll be hearing from those programs who are sharing examples of the protocols and guidelines that they've put in place for COVID-19. We'll be hearing about how to navigate some of those new roles impacting home-based medical care. And then we'll be talking about some special concerns for home-based programs and providers in the era of COVID-19. So at this stage, I'd like to go ahead and turn it over to Dr. DiCieri. Can you hear me? Yep. There you are. Thank you. Okay. Great. Thank you. So I'm going to speak a little bit about our variety of programs we have at Mount Sinai, but most of the time I'm going to focus on the Mount Sinai Visiting Doctors, which is the home-based primary care practice. This comes from a slide set that I put together, or a number of us put together, and this is probably the fifth version of it since the beginning of the COVID outbreak. And it is already evolved again since we put this together, and that's kind of the nature of what's going on here. So I'm going to talk a little bit about our general official procedures, the screening protocols we're using, our phone calls, how to do a home visit, which we're doing, you know, unfortunately now very few of. And then, although not on the slide, I do want to talk a little bit about what's happened in the last couple days and how we've been spending most of our time really, really talking about goals of care with our patients and getting proactively comfort packs into patients' homes, which I think is probably the most effective thing we can be doing right now for our patients. We'll go to the next slide. So what we decided for our home-based primary care program and also our palliative care program is that the clinician is determining if there absolutely needs to be an in-person visit at this time. We try to offer telephone calls or video visits, reschedule, but we will do some visits at this time for non-COVID, non-respiratory-related illnesses. There was a brief period of time where New York State was doing community testing for COVID that went away last week. And there's really no community testing at this time, so we definitely do not do testing in our home visit program, and I know that's one place that will diverge in different places across the country. The only way you really can get tested at this time is in a hospital setting if you need to be hospitalized. So what we did is that we decided that all the visits would just be canceled at this time, and then the providers determine if there do need to be a few visits for very specific reasons to see patients. And so what we do is we have all visits telephone screened the day prior to the visit, and then if it's a Monday, we'll have the provider re-screen on the Monday morning since a lot can happen in the weekend. If it's a social worker visit, they will do their own screening prior to the visit. And the screening, you can go to the next slide, is very similar, and actually has changed a lot over the last couple weeks or before it was really like where have you traveled to or have you had an exposure, and now the screening assumes complete community spread and it's really focused on the symptoms of COVID. So that's where we have the guidelines here about when screening has happened. Hospital at home is a little different for us because there we have to do visits daily, and there's often three visits daily. So we're screening once a day, every day during the acute phase just to see if anything happened overnight, a new family member becomes positive or something like that, to be able to understand where everybody is. So these are the questions that our administrative assistants will ask, which are questions like, do you have a recent onset of a fever, do you have cough, do you have any flu-like symptoms, and then have you had any close contact recently with that. And then these are very specific protocols here that I wrote in, it's how we document that in EPIC at the bottom here of the slide. And if any of that stuff becomes yes, then we get routed to a nurse who's going to do a little more investigation, and then it gets notified to our physician or NP, and we would definitely want to make sure that no one's going out on visit. We also here at Mount Sinai, you know, all medical students were pulled from all clinical rotations. At first, they were pulled just from anything that would be potentially frontline, but then for all clinical rotations, and similarly, our residents have been mostly redeployed to inpatient. We have no trainees that we're having to worry about in this process, but we certainly want to make sure that the providers know if any of these things become positive before going out on a visit. Then we have another scenario, which is just phone calls coming in, that, you know, we take care of about 1,200 patients in our practice, and so when a phone call comes in, this is the protocol that was put together a couple weeks ago about what the admin does when they get the call, how it gets routed to a nurse who does then more triage screening, and then that gets sent to the physician or NP to make more of a triage decision. Initially, at first, the first version of this, every single case was reported to our internal infection prevention site. Of course, now the volume is way too high for that, but they do want to know about if we're transporting someone in an ambulance to the hospital because we're using special services or special notification to services who are doing those transports. This was our smart phrase that the nurses were using to follow up for the admin about the coronavirus. You can see they're still at the bottom there, some of the, have you traveled to specific countries? This has pretty much been removed at this time from the protocols. This is our standard ambulatory screening algorithm for the Mount Sinai Health System, and I just have inserted on the left side or any of the yellow, sorry, any of the blue boxes how we work at the visiting doctors with that. When you're on a home visit, if you've fully screened everyone beforehand, you put on your surgical mask prior to going into the home, and then the first questions again you ask are the same questions you've asked on the telephone, which should be negative because you've already screened, but you need to do one more time. Have you had a fever, any symptoms of cough or shortness of breath? If that is still all no, then you go ahead with the visit as you had planned. If it is yes, then you need to step back six feet, and we do provide one set of PPE for our providers, and so they can then put all of that on and assess the patient at that point in time to see if the patient can stay at home with those symptoms or if they need to be potentially transported. So, we do provide that for our staff. There's minimum PPE around, but that we do have, as I said, a set for everybody. Go on to the next slide. So, this is really what, you know, some more specifics on that. So, you would step six feet back, you would do your hand hygiene, you would put on your PPE, which for us is a surgical mask, a face shield, the contact isolation gown, and gloves. We're not using N95, and then we put a mask on the patient. So, there's a mask on the provider and a mask on the patient. Again, I know each place has slightly different protocols for these things, but that's ours at Mount Sinai. And then you can put the chucks and your equipment on that, and then after the visit, of course, more hand hygiene, and we have a trash bag that we provide each provider, and then they put all those things in the trash bag. Mount Sinai did start this week reusing face shields and N95. So, for us, really, it's only the face shield that could potentially be reused, and we have not yet figured out a process if we needed to do that. I must say, you know, this has now been three weeks under these protocols, and not a single provider has broken into their PPE bag. I think because, A, we're doing very few home visits, maybe two a day for the whole practice, and otherwise, you know, the screening is really good for the ones we do do, but we do want to be prepared if needed. And this is a Mount Sinai equipment wipe that we use. We used to use the purple and the blue on the left, and now they're the green and the blue. But, again, that's just the brands that Mount Sinai uses that we have always used pre-COVID. You know, this has nothing to do with that event to clean our equipment after every use. This is the preparing for the home visit checklist. We realized that not all of our providers had soap and paper towels with them, which we made sure that they had in case ever their hands are soiled, and that is a pre-COVID issue. We should always have that, but we restocked all of that for our providers. And then these were – we had specific – our internal education software is called PEAK, and so we had PEAK modules we had to do on proper donning and doffing. One of the nice things about all those – those are words I didn't get to often use, donning and doffing the gowns. So we went through those with everybody while we were, you know, getting ready for this. All right. Thank you so much. So I know – did you – Can I say one more thing? Yeah. Just one thing that wasn't here. I think that the – what we've really spent much more time on the last couple days is something that I think is really, really important that I want to relay, which is getting our patients ready. So yes, this PPE is really important. Yes, the screening is all really important. But the reality is, is that goals of care are some of the most important things that we can do at this time. So yes, we should have always done that, but we've frankly called almost all of our patients and been asking them, again, what are your goals of care? What would happen if you got COVID and you were having respiratory symptoms? What would you like to do? And really documenting that in a clear way. We know that it will be very hard. There's already shortages of a variety of meds. So we're proactively sending to people whose wishes are never to go to the hospital, Roxanol to their home already now. And I think that when the time comes, if something happens, it'll be really great to have that. We've had a number of our patients already die of COVID, and it's been a lot of nights on call helping those families manage those symptoms. And hospice has not been able to keep up. We have two main hospice agencies in our area and multiple smaller ones. One of them is not able to take a COVID-positive patient at this time, and the other one is. And even if they do, it's a two to three day before they can intake a patient. So I think those are some of the absolutely most important things we can do right now with our patients are some of the most vulnerable. Thank you. I just really want to make sure I got that out. That was great. Thank you very much. So we're going to switch over now. Dr. Carla Parisinoto from UCSF Care at Home. Great. Thank you. Nice to not really see everyone, I guess, but talk to you in a vacuum. But regardless, it's great to be a part of this call and hope that some of what we were doing at UCSF can help the rest of you. And I want to start with talking a little bit about and echoing what Linda said as the backdrop to this whole conversation, which is we have an opportunity to learn from communities that are experiencing this ahead of us, that those are at the same level and those that are not quite where we are. And so a lot of our modeling has been we have to plan for our current situation and for the future. And that means looking at what is our availability to see people right now, what is our current PPE status and what are our relationships and supplies with our current home health agencies and hospice. So a lot of it is proactive planning right now for our group as we're not in the midst of things as New York is. I'm going to cover a couple of things. The first thing, and I wanted to have my focus a little bit different than what Linda has covered. So the first thing is really thinking about office versus telecommuting and thinking about in your team or in your group, depending on the size of your practice, who are actually essential staff. So that means thinking about in our practice where we have, I think, somewhere between 12 and 15 medical providers, three front office staff, essentially as you would consider them, two social workers and two RNs. We've really triaged and thought about who needs to be actually on site in the office versus working from home. So what that means for our practice is that on a given day, just to handle faxes and urgent phone calls, we have two of our providers, either a physician or nurse practitioner on site. They may not be there the whole day. One of them will. The other one can potentially go home if things aren't busy. One of our nurses is on site. Our social workers are off site. And our office staff, which are scheduling appointments and handling phone calls, are currently doing it at our actual office, primarily because of tech issues with setting up our remote phone, which is crashing computers when everyone's remote. So we've really had to think about what is the current situation and what is a backup plan, which has also meant, for example, setting up my computer to manage faxes at home if for some reason we end up not being able to come into the office. Melissa, you have to tell me because I can't remember. Yes, thank you. So the next part is in terms of staff screening. As we've learned from cases around the world and thinking about what is one of the things we can do for prevention amongst your staff. So how are you screening your employees at the beginning of the day? So this has been an evolution. And there's different ways to do this. One thing is this very simple paper formulation at the beginning of the day when people are coming into the office or also thinking about how are you managing your remote workers. We at UCSF partnered with an organization called Conversa Health. And so every morning when I'm coming to work or supposedly going to work, I get a note to my cell phone. And I have to answer these questions, which are really regarding really around the very standard COVID questions for employees or health care workers. If I don't have any symptoms, I get a note that says I'm cleared for work and I can move forward. So this has been a really great thing that is UC wide. It is probably not realistic for small practices. But think about what you can employ in your group to make sure that your health workers are safe and that you're assessing them on a day-to-day basis. There's a lot of shame, as you guys know, around this in terms of do I have it? Do I express my symptoms? Do I cough? Is everyone going to look at me funny? So this kind of creates a way to be able to report symptoms without in-person barrage of complaints or concerns. Next slide. Okay. The second part, the rest of what I want to talk about right now is thinking about, again, because we are at a different stage than what New York is right now, we're trying to think about what can we do proactively for our patients right now. These are things that we have started doing in our practice even before COVID and has just been accelerated. So what that means is that we are trying to assess our patients in our practice. We have about 400 patients, but we are also expanding this to our outpatient geriatrics practice, which is another 1,000 patients, to think about how can we proactively reach out to people, set them up for telemedicine capabilities, assess them for symptoms, check in with them socially and in terms of their social needs, and make sure we have an emergency preparedness plan. So this is what I wanted to share. So we started several years ago a way to screen our patients or assess our patients for how willing and able will they be able to actually use technology to do video visits with us. So there are certain things like asking, do you have an internet? Do you have internet? What kind of technology do you have? If someone doesn't even have a smartphone or a computer, you're not going to be able to use telemedicine. But if you have some of this information that can help you triage how likely is it that you will be able to use telemedicine with this person. The reason we ask about MyChart, MyChart is the epic-based communication system, is that we can push out instructions on connecting to the platform that we use at UCSF, which is Zoom. So that is why we ask about that as well. So that's about telemedicine readiness. Next slide. And then the other thing that we did, and again, this is something that this started unfortunately for us last year at UCSF because of the fires in Northern California. So what we did with, what we've done with all of our patients that are newly enrolled into the practice, and we've had to go backwards now and look at people that didn't have this assessment, is get a sense of how sick are these people. And in our priority, if we were having to triage and evacuate people in an emergency situation like a fire, or even now with COVID in terms of how likely is this person going to need to give assistance to, if they have symptoms, will they have someone that can help them, or are they really on their own? So we do this, excuse me, emergency triage assessment on our patients. And then what we do on what we call a care coordination note at the top of the chart, and you can see this at the bottom of the screen, is we will write two things. Either are they telehealth enabled and with what platform? This, I won't spend time talking about the types of telemedicine platforms. I think we'll talk about that later. And then we also indicate what level triage they are, so that we know a little bit more about that. Next slide. And then the last thing, again, is thinking while we have two things. While we have a little bit of, somewhat of a calm, more in terms of, not calm in terms of organization, because there's a lot going on with organization and planning, but our patient load in terms of visits right now has not reached where I think we will be. So we're trying to proactively reach out to people. We're also thinking about because we are an academic institution and there are many students that don't have anything to do right now, how can we utilize other team members? So either other team members, our social workers, for example, who aren't doing in person visits right now, can they do some of this assessment? And are there other people within our institution that can help? So we're reaching out to people proactively, saying, just letting people know why we're calling them and asking specific questions about where it's your status of medications. And if we anticipate they're going to need medications, doing the refills now. Anticipating needs about medical supplies, because as you can imagine, we'll start to see issues. And we already started, we already have started seeing issues with people having issues with gloves and other supplies. And then understanding of getting a sense of where people are with caregivers. Since many of our patients are low income and rely on city and state funded caregivers, what is the status and is there a backup plan? And then understanding if there's any food access issues so we can triage appropriately. And then lastly, leaving it open in terms of their other concerns. And we're spending some time actually doing some discussions around loneliness and isolation, which is a huge issue amongst our population, even more so now in the settings of COVID. And as Linda mentioned, we were doing this already in terms of advanced care planning, but really taking a very proactive approach of going through our list and saying, who have we not had discussions with? And let's prioritize that. And finding that many patients are actually, and their family members are wanting to talk about this right now. So whereas other times it's a little bit more taboo sometimes to talk about, because this is so prevalent in people's minds, people want to have these conversations with us. I think that may be it. That is. Thank you so much. All right. We've got some great information. Our next presenters are from UW Health in Madison, Wisconsin, Dr. Barzi and Dr. Detallo. Thank you. So Dr. Barzi and I will be sharing some of our experience here with our home-based primary care program at UW Health in Madison. And we have a lot of other team members who helped develop these policies and procedures on the call. So wanted to thank the rest of our home-based primary care team as well. And like Linda said, things are changing every day. And it's very possible that some of the information I share with you today will change tomorrow. So we wanted to share the link. All of the information that I'm sharing with you today is available online at this website and may be updated on future days. So as Carla and Linda said, your strategies may vary depending on where you are in the spread of the epidemic. So this graph is just one predictive model of hospital capacity in Wisconsin. It comes from the website referenced below, covidacnow.org. And it's an estimate of when the hospitals in Wisconsin would reach capacity under different scenarios. So in the red scenario, if we did nothing, this estimates that our hospital beds would be filled around April 12th. So we are trying to take a proactive approach still at testing and isolation. There is community spread in our county. And in several counties in Wisconsin. And if you would like to check your own state to see how your strategy can match where you are in the curve, you can go to this website and click by state and look at the predictive modeling. So there's a few areas we wanted to highlight with our experience at our home-based primary care program, which is a small program and relatively new. We just started in November. We have a census of less than 50 patients right now. But the screening and testing protocols that we're using are universal testing here in UW. The same testing criteria in the ambulatory clinics that we're using for home-based primary care. And then we also wanted to go through our panel management approach. The outreach that we're doing. The patient education and counseling that we're doing. The safety checks that we're doing. To try to protect patients on our home-based primary care panel. And then the final thing we wanted to highlight was what's the PPE use and conservation strategy that our institution is taking. So I wanted to share the testing criteria that we're using currently at University of Wisconsin. This is in the setting of us having a COVID-19 vaccine. And so we're using the COVID-19 vaccine. This is in the setting of us having adequate tests right now. So, you know, if you're in a setting where testing is not available or the demand is outpacing the testing, different criteria may be appropriate. But at this time, we're able to test anyone with new respiratory symptoms who has had close contact with a known case. Or anyone with acute respiratory symptoms who belongs to a higher risk population. And I think this is really important. I wanted to share how we're defining a high risk population. So this could be high risk to vulnerability because of their comorbidities. And there's some examples listed here. This is not an exhaustive list. We can use our clinical judgment if we think our patients are at high risk for complications due to their comorbidities. Vulnerability also being anyone who may be pregnant. And then also we're able to get testing for people with respiratory symptoms who are at high risk due to exposure. So this includes healthcare workers and congregate living facilities. And for our home-based primary care program, about half of our patients do live in assisted living or independent senior living facilities. And so our institution is taking a proactive approach with our partnering facilities. And trying to help them prevent outbreaks in those settings. And we do have the capability of getting testing either at a dedicated respiratory clinic site through our health system. Or in the home environment. And so we actually ordered our first COVID test at home today. We have a partnership with a home health agency who's going out and doing those tests with us. This is a script that our team is using across UW for any patients with positive tests. I'm not going to read you the script. But I wanted everyone to have it. And I think the important things as part of this script are to emphasize self-monitoring. Who to call if your symptoms get worse. And giving instructions for self-isolation. So I wanted to take a minute to review instructions for self-isolation. And kind of give two scenarios, real-life scenarios that happened. So I have a family member in another state who could not get access to testing after a known exposure and developing symptoms. And was told to stay at home. And assume they have it. Which is great advice. But really didn't receive any more instructions on what to do staying at home. And I want to contrast that to my own personal experience I wanted to share. So I also had a criteria for testing a few weeks ago. And was able to immediately go to one of our respiratory clinics through employee health. Get tested. At that time it was taking about five days for results to come back. Right now we're getting results back within 24 hours. But I got detailed instructions. Written instructions on how to self-isolate. Which I was able to implement. Which is actually quite challenging. To stay at home. To stay at home to use separate bedrooms and bathrooms if possible from other household contacts. To clean high-touch areas including doorknobs, remote controls, light switches every day. Not to share any personal household items including towels or silverware or dishes. To wear a mask when in the same room as others. And when I got tested I was sent home with two surgical masks. And then to postpone all non-essential medical appointments or to call ahead if you do need to go to a medical appointment. Our criteria for discontinuing isolation right now are that you're free of fever, cough or other respiratory symptoms for 72 hours. And seven days have elapsed since the day that you first experienced symptoms. And then also to educate caregivers or other household contacts that they also need to quarantine, meaning that they need to follow these isolation recommendations, sharing a household with the person on self-isolation for 14 days after that last contact with the person who had COVID-19. So our team has put together a COVID-19 playbook for the home-based primary care program, and I'm going to let Steve describe that. Yes, thank you, Melissa. The idea is that obviously, like the other programs that were described today, we want to be as proactive as we can be with this very high-risk and vulnerable population. And to the extent that we can protect them from exposures, including us as health providers who might be the vector coming into their residence, and if we don't take the appropriate precautions, we could be the source of infection for our patients. So the whole team has really, along with our UW group, has really thought about and then crafted new workflows, which are described below, more or less, to address these concerns. We also feel that not only do we want to protect our patients and be proactive about minimizing their exposures to the health system, we also want to prepare them, as Melissa had shared, with regards to educating them about what does social distancing mean and, as stated, what does shelter-in-place suggestion mean. With our workflows, I'm not going to go through each one of these, but we do think about what type of a service they're going to need. And with that, there's a fairly limited number right now that are having in-home visits. We know that in a number of our sites, the ALS and the skilled nursing facilities have gone to lockdown. And so they're really not allowing us, even if we felt we needed to, to come in. And so we need to find contacts or allies within those sites to be able to kind of be our hands and eyes when we are gathering data and making medical decisions. If we anticipate we are going to be making a visit into the home, we have a little bit of a drill or a safety huddle, if you will, where we take really the most recent information about PPE protection and all that, which is evolving almost day by day. And we want to have at least one other team member kind of talk through the process with us so we know we're going to have the right materials, the supplies with us, and that we're going to go through the appropriate precautionary measures. Next. So as I think was described actually by the UCSF program, one of our nurse practitioners and our social worker can also do this, are reaching out to all of our high risk or vulnerable patients. And in doing so, we are inquiring with the following questions here. And I want to point out that they pretty much mirror, I think, the questions you may have seen earlier. But we also are exploring the last point, which is how are our patients doing emotionally with all of this? Because there's a lot of fear mongering that's going on. And anyone with underlying mental health issues at baseline are not likely to be doing as well. And so we want to have a sense of that so that we can react accordingly. Next. So as I mentioned, we had that huddle process. And so we really are trying to think a lot about what guidance we have about using PPE. And so with this, I'm going to pass things back to Melissa. So this is just a table that outlines, it's not very detailed, that outlines three different levels of PPE. And part of our safety huddle is determining which one is appropriate for an in-person visit if we do it. So starting last week, there's a new standard that's happening with all of our face-to-face visits for home-based primary care for ambulatory clinics. When a face-to-face visit needs to occur, we're using a mask and face shield for all patient contact. And I'll talk more about that in a minute. But that's both meant to protect patients from us, since we can transmit disease and be asymptomatic, and also to protect us from them. We can reuse that mask and face shield indefinitely until it falls apart, essentially. And I've been doing that for the past few days. I actually had a hospital shift yesterday and went into about 20 patients' rooms with the same mask and face shield. These are patients who are not on isolation. And I'll share the cleaning protocol. But I found it to be very feasible and didn't delay me from going through my routine at all. In addition to what the ambulatory clinics are doing, we're being extra careful not to bring germs into the home of our homebound patients who may otherwise be safer without us visiting them. So in addition to the mask and face shield, we're wearing shoe covers. And also we have two reusable washable barriers, one for the bag and one for us to sit on when we're in the home. For people who are on isolation, who are having respiratory symptoms, they're divided into low risk or high risk. The low risk has more to do with our interactions with them. When are droplet and contact precautions appropriate? The high risk is needed for aerosol generating activities, which does require the airborne precautions and the N95 respirator masks for us. And we do find that we encounter these aerosol generating activities in the home. So we wanted to share situations in the home where we would be taking precautions with the N95 respirators. I wanted to just address two kind of myths or concerns that I've heard out there on message boards related to wearing a mask and face shield for all patients, just because our experience differs from those. So I have colleagues at other places who have been told, you know, don't wear a mask or face shield because it will scare the patients. That hasn't been our experience. So I found that wearing a mask and face shield for all patients can actually be very reassuring to them and communicate important messages. So I tell them, you know, we're wearing a mask and face shield as a precaution. It's more meant to protect you from us. And I think that communicates that patients remain our number one priority during this emergency, that we can be infected without showing symptoms and that anyone can potentially be infected, reducing stigma. The other concern that may exist is about wearing a mask and face shield for all patients encourages wasteful use of supplies. Certainly supplies differ in different locations, but being able to do this on a daily basis, you know, reuse, practice that as part of my daily routine, reusing the mask and face shield, I found encourages a conservation mindset that I really didn't have before. And this is just our protocol. The full protocol is at the bottom for reusing the mask and face shield. Again, this is for patients who are not on isolation. We wear the same mask patient to patient day to day. The reason why we can reuse the masks is because the face shield protects the mask from contamination. Otherwise the outside of the mask would be considered dirty. And then the face shield is what can be cleaned. So after each patient face-to-face visit, the face shield is cleaned with cavvy wipes. It dries for two minutes. If there's streaks, an alcohol wipe can eliminate it. And then at the end of the day, the clean mask and face shield are kept by an individual in a paper bag or hung on a hook. This is for patients who are on isolation with typical interactions that you may be doing during a visit. We're using a surgical mask with a face shield, gown and gloves for this. And this really encompasses most of the ambulatory care visits. There's a higher level of PPE required for aerosol generating activities. This is where the N95 respirator or plus face shield or PAPR are required. And I'm going to, on our last slide, let's let Dr. Barzi run through the aerosol generating activities and which ones we may encounter in the home. Yep. And this doesn't take much commentary, but we are very sensitive about anyone who's been using CPAP or BiPAP, of course, nebulizer therapy. And then as you go down the list there, we're even sensitive about people who have high flow oxygen, but maybe not six liters, because we know that our patients can and will sometimes dial up and dial back on their oxygen levels. And then the other items is, which are really not so relevant for our home visits, but are listed in our UW health system. So we really are very conscious and the timing of how long after remains to be determined. So I think we tend to be very careful when individuals have been using BiPAP, CPAP or high flow oxygen. And with that, I think that encompasses our experience to date, which as Melissa shared is ever evolving. And our team is doing an amazing job to try to adapt to all of the day by day changes. Yeah, very good. Thank you so much. I want to acknowledge that we've got a lot of questions coming in and many that are asking for, you know, what kind of, you know, washable, reusable barriers do you use or what kind of medical, where do you, what medical supply companies in a particular area and so on. We'll address some of those questions on our LinkedIn group page, and I'll tell you more about that later. But I want to turn it over now to Brianna to talk about the Medicare rules changes. Thank you. So I'm going to give everyone an overview of the Medicare regulations. There are still some unknowns, but what we know today as specific to the 1135 telehealth waiver, I do want to start with a little disclaimer that especially if you're part of a large organization or academic health institution, they have probably most certainly actually implemented their own billing policy. And so this is not to contradict any guidance. You do need to work with your organizations and stakeholders, but I'm going to go over the federal guidelines from CMS for traditional Medicare beneficiaries. So on the next slide, this is high level what the 1135 waiver is. So under the emergency declaration from the president, any date of service starting under March 6, 2020 for office visits for certain hospital and other specified set of codes can be paid regardless of the location of the patient or the provider under this telehealth waiver. They're going to pay those at the same rate as an in-person visit to help with reimbursement during challenging times. We all know pre this that Medicare was very restrictive. The patients had to be in a rural or healthcare professional shortage area, and the home was not an originating site. They have removed those requirements temporarily under the waiver so that patients can be at their home or any setting of care to receive telehealth and to reduce the spread of patients traveling and potentially, you know, being contaminated or further at risk. The government has further said that normally telehealth requires an established provider and patient relationship, and they have said that they do not plan to audit during this public health emergency because they want to realize there may be some new patients that still need to be treated. And in a recent press release, if you're a program that's participating in the quality payment program or MIPS or in a different alternative payment method, they are implementing a extreme circumstances and uncontrollable circumstances policy, whereas they've extended the submission deadline to April 30, but if you do not submit your MIPS performance data, you're automatically, you don't have to do anything. You're automatically qualified for that policy and receive that neutral payment adjustment so that you don't have to worry about that. And then the last bullet point, these are the providers that can currently bill for telehealth services that's still subject to their scope of practice. So clinical social workers, you know, you still, they don't build the office E&M codes, they build their psychotherapy codes that are included on the list. And on this next slide, these are the specific codes pertinent to home-based primary care. So you can see what is included on and covered under the waiver specific to E&M telehealth services is the office visit, the transitional care management code, advanced care planning codes, which we heard how important those are, as well as some inpatient and annual wellness visits and the skilled nursing facility. And I've included the link where you can see the complete list of codes that are covered under this waiver. I did want to take a moment to address a question that came in that I don't have a bullet point for, but under the emergency declaration, they are temporarily waiving the requirement for providers to be licensed in the state that the patient resides if they have an equivalent license in a different state. So normally the provider has to be licensed in every state that the patient resides where they perform telehealth services, and that is temporarily waived. You can find that regulation in the emergency declaration, and we have links for that for you later on. But going to the next slide, so again, if you're billing any of those E&M services, you do need to have audio and video telecommunications. It cannot just be a phone call only. They do need that real-time communication between you and the patient. To make that more feasible for programs that have not already implemented telehealth, they did relax HIPAA requirements. So acceptable two-way communication could just be on the patient's smartphone using Apple FaceTime, Skype, Zoom. Doxy.me is a free HIPAA-compliant solution, so certainly, obviously, if you have an option to use a HIPAA-compliant platform, please do so. But they are waiving that requirement under the public health emergency, but you cannot use public-facing applications such as Facebook Live. And when you submit these E&M claims, that would typically be furnished face-to-face, but during this state of emergency you're billing for via telehealth, you're going to want to use Place of Service 02 for telehealth rather than, you know, most practices use Place of Service 12 as the home and so on and so forth for other places of service. Modifiers is a big question that has come up with billing. What I have for you here is, again, CMS traditional Medicare guidelines. This is published guidance in the FAQ as well as the fact sheet published on March 17th that these modifiers are only used under these circumstances. Commercial payers in some Medicare Advantage plans may be requiring these modifiers as well as modifier 95, and that's why it's advisable to contact your local Medicare administrative contractor for specific guidance or proactively reach out and work with your Medicare Advantage payers. Also, because Medicare Advantage has flexibility to cover telehealth as their supplemental benefits and has a lot more flexibility, and especially if you have a value-based arrangement with them, now is the time to reach out to them in a time of crisis and see what they can do to work with you. And on the next slide, documentation, I want to spend a moment talking about that. Again, when you're billing for an E&M visit that you're doing via telehealth, you still have to document appropriately. So, document you as you would for a face-to-face visit. That means you still need to have a chief complaint. You still need to have HPI, which, reminder, could be a status of three chronic conditions, which is relevant for this population, pertinent review of systems, past family or social history. Keep in mind, exams are going to be limited. With that two-way video, you can document some observational exam findings, and that is acceptable, but that's probably not going to get you to the highest level of service. So, do keep that in mind. And then your medical decision-making and your assessment and plan, you always want to support medical necessity. They're still going to look for that. So, documenting each condition that you addressed, what's your assessment, what inherent risks to the patients might be covered, and all of that is going to support necessity. And I do want to take a moment to talk about consent. During this time of crisis, I'd recommend a smart phrase or a macro that indicates that the patient has consented to something along the lines of the patient has consented for a telehealth visit due to the COVID-19 pandemic, you know, performed via whatever method you perform that on, and then if you are using a non-HIPAA-compliant platform, that you've made them aware of any privacy risks. So, a smart phrase would go a long way, again, to just a best practice, but that's a recommendation at this point. And while I mentioned kind of the big question is, what do we do? Because home-based medical providers use the home visit and domiciliary CPT code, and we know that's not currently included on Medicare's telehealth list. So, at HCCI and as well as the American Academy of Home Care Medicine and our other advocacy partners, we're actively seeking answers. As of today, I do not have official clarification, so I'm going to lay out all the facts for you. One, if you contact your local MAC, I have been working with a practice. There's a member of HCCI's practice advisory group that is getting answers within a couple days, and they are working with her to bill for services. So, contact your Medicare administrative contractor for guidance. My concern, especially from a compliance and risk management standpoint, is if you have historically only ever billed home and domiciliary visit codes, and you all of a sudden start billing office visit codes via telehealth, is that going to put you at a potential audit risk? And I wish I had a more concrete answer. Like I said, this is changing every day. As of right now, I don't. However, I can share there have been a lot of respected organizations and practitioners that are going forth billing the office visit codes, especially those that do have, you know, offices where they could render services or perhaps do render services, but not all home-based primary care providers do. And on the next slide, these are the codes you're probably going to be using for your established patients. Keep in mind, established patients is a two out of three. So, if you don't get to that detailed exam, you can use the history or MDM to support a 99214. And I also think that many times it could be appropriate, especially during this pandemic, to bill on time. So, for time, you know, you don't have to worry about meeting those other requirements. You just need to document your total time, that greater than 50% of it was spent on counseling and coordination of care, and then your note either needs to support that or you need to briefly describe the nature and the extent of the counseling or what kind of coordination you care, and then you can bill based off the typical time threshold. So, keep that in mind if you are going forth. Again, I don't recommend doing so without official guidance from CMS or your MAC, but you could, you know, use this as a guide to determine the appropriate level of service if you are choosing to use the office visit code set. And on the next slide, for those of you that may have seen this, this is included in a lot of Medicare's fact sheets, but it's a nice visual for what telehealth is. And there are other services. So, if you are just doing audio only phone calls, virtual check-ins, G2012 in particular, can be just for a five to ten minute phone call. E-visits are for patient portal communications. Both of these services were pre-COVID-19. So, these are never subject to Medicare telehealth regulations. The reimbursement is fairly low, but they are available to you, and HCCI has detailed what these services are and the requirements in two previous articles that are available on our COVID-19 information hub. So, you can find more information there. Also, keep in mind care management. So, if you are doing chronic care management, now is the time to really make sure you're capturing and you're billing for your time as an additional source of reimbursement. And don't forget if you, as the provider, are spending that time, you know, 99491 for 30 minutes of provider time per month of chronic care management does pay more than the traditional CCM, about $80 compared to the 40. So, keep that in mind when you're determining your billing strategy on what you need to do for your practice during this time. And on the next slide, I just want to take a moment to acknowledge Medicaid is handled at the state level, so not Medicare Medicaid. Since I made these slides, it changed again. There's now 23 states that have Medicaid waivers. This is not specific to billing. This could be things like waiving prior authorization or provider enrollment capabilities, but just wanted to acknowledge that Medicaid, and you can see the link there, is handled at the state level. And where can you find more information? So, HCCI has links to all of these on our COVID-19 information hub, but here's where you can find additional information, as well as I did want to acknowledge that there is the national telehealthresourcecenter.org. They are federally funded. They have a lot of free resources and technical assistance, and they'll also connect you with their local telehealth resource center, which are dedicated to helping practices implement telehealth, and can be another great resource for you during this time. Okay, thank you so much, Brianna. I want to remind everybody, if you can please submit your questions via the question box, we commit to getting back to you via the LinkedIn discussion group. You can also, I'm going to give you another way in which you can connect with us directly, specifically even Brianna, for some of those coding questions. But right now, I want to turn it over to Dr. Paul Cheng to just discuss quickly some of the special concerns for our home-based programs. Thank you, Melissa. Time is short, and I'm going to keep my comments brief. You have heard enough protocols and guidelines. I am not going to go through them. I'm a full-time house call doctor. My practice has about 750 patients as part of Northwestern Medicine outside of Chicago, taking care of patients in suburban settings. These are just some comments and thoughts as my practice, myself, struggled in terms of how to manage our patients in the COVID crisis. You heard about telemedicine in older patients. What are the potential challenges that we may encounter when we try to take care of them electronically? Now, for example, some of the issues that we ran into, the issues are, do you have an app? Do you have to go to an app store? Do you have to download an app? And the barriers that creates when our older adults struggle with even more simpler directions. So that's a potential barrier there. And as we think about pushing off our patients and delaying visits, what will your schedule be like a few months or a few weeks down the road? And how will you stratify visits again to what patient population are you going to see earlier than later? We've heard about a supply shortage, and I encourage you to work with your system in getting the supplies that you need. And also have an open dialogue with the patient and the family regarding discharging home health, occupational therapy, physical therapist on hold temporarily, or even perhaps not necessarily ordering a lab draw, perhaps a few weeks later, because we want to minimize contact with our patients. And one thing I do want to bring out is this has been a lot of work from my office and my staff and myself trying to follow all the guidelines and take care of our patients in new ways that can add more stress to your staff. So be aware of the emotions of your staff and how staff and how they're doing. Make time to meet virtually and have a dialogue and address questions that might become an issue for the office since we're now more disconnected given the current crisis. Next slide, please. Yeah. Again, as Brianna has said, there will be some impact regarding revenue since we're making less in-person visits, and the coding and the billing and the charges will not be the same. We do need to think about who really needs a visit from us, a face-to-face visit. There are wounds that really needs to be addressed. I saw a wound care patient today that needed a treatment. It's really difficult to do that over the phone. Other critical symptoms or conditions that would demand a on-site visit need to think about who patients are in your practice. Brianna has talked about Medicare rules. It does come up in my mind about I don't want to be audited and I want to abide by the rules and do it correctly. So check back with the ACCI on a regular basis. We will do our best to provide you with the most up-to-date information from Medicare. There needs to be some additional education and counseling for our patients. As Melissa and Steve has already talked about from UW-Madison, you can take some of their ideas and incorporate it into your practice on taking care of our patients. All right. So in our last few minutes here, I want to encourage you to please enter your questions into our question box. Again, we commit to responding back to you. It's nice that we can see who is asking the question. We will follow up with you. We also invite you to engage with us in a couple of different ways. So let me tell you about that. We see this webinar as the beginning of a dialogue and the beginning of a new community. And oops, I didn't mean to do that. So we invite you to join the Home Centered Care Institute COVID-19 group on LinkedIn. You can search for us in that way. There is a direct group URL here at the bottom of that slide. And of course, all these hyperlinks are embedded in the PDF that we sent to you or that you have the opportunity to download that will be sent to you with the recording of this webinar. I also want to call your attention to HCCI's information hub for COVID-19. And this is something that's accessible right from our homepage. And we are constantly adding new resources and information that's available to us, either produced by HCCI or produced by one of our partners. I wanted to also share that in this time when we're all thinking about infection control, HCCI has made the decision to make the online course that we developed a while ago on infection control available to you at no cost through June 30th. So you can go to our website right now. You can get that for no cost. And it's a great primer for you on how you can identify some of the risks associated with home based care and mitigate those infection risks. And then I want to let you know, we have of course, our HCCI Intelligence Resource Center. And this hotline that you see on the left hand side of the slide, that email and that phone number will connect you directly with our staff and we can assist you with especially any of these coding questions. So please don't hesitate to reach out to us directly with anything. And then I'm thrilled to be able to tell you that we are collaborating with the American Academy of Home Care Medicine to bring to you as part of our HCCI Intelligence webinar series. Our next one will be another update because we see how quickly things are changing, you know, and we want to check in with you again in a few weeks on this issue to see what other information that we can share with you on that. So please mark your calendars. You can register now via our HCCI Intelligence page on our website. That is my last slide. I want to thank our presenters so much for sharing this valuable information with your colleagues. And I want to thank all of you who participated in the webinar today. We look forward to continuing to engage with you on the LinkedIn page and through our hotline and wish you a very good rest of your day. Thank you so much everybody.

COVID-19

home-based primary care

providers

screening protocols

telehealth guidelines

reimbursement changes

strategies for home-based care

personal protective equipment

billing

challenges