a joint workshop for home-based care teams. This event is being presented by the Home-Centered Care Institute and the Center to Advance Palliative Care. My name is Melissa Singleton and I am Chief Learning Officer for HCCI and we're glad you're here. HCCI is so appreciative of the opportunity to collaborate with CAPC on this workshop. And in part, because our mission is so aligned with theirs. HCCI is a national nonprofit dedicated to creating universal access to high quality sustainable house call programs that support full service solutions for managing complex illness and chronic diseases. So just a few statistics to get you excited about today. We have more than a hundred people registered and approximately 45% are from hospice or community-based practice. And approximately 30% are affiliated with a hospital or a health system. And about a quarter of you are with an independent practice. And we have attendees joining us from all over the US and several as far away as Hawaii. And we so appreciate them joining us at this very early hour for them. So welcome. Before we really get started, I do have a few housekeeping announcements. And the first is interactive. I need for you to take some action here and rename yourself in your video screen. And actually one of the first things we want you to do is mute yourself too, if you're not speaking. But the other thing is so that we can help identify you, would you please go to where your video screen is and you should see three dots there. If you click on those three dots, you have an option to rename yourself. And we would ask that you rename with your first name, comma, and then the name of your practice. And acronyms are okay. If you look at my name, you'll see that I'm Melissa, comma, HCCI. So if you would please do that. And then I'm assisted today by my colleague, Sarah Tolan. And I'm gonna ask her when she has a moment just to kind of put that instruction also in the chat to let people know that that's how we want them to identify themselves when they come in. And again, we ask you to stay muted if you're not speaking to the group. And we encourage you that at various points in time today to have your video on. We're gonna be using breakout rooms so that we can have some of that face-to-face interaction, which is so important even virtually. So please be willing to do that. Throughout the day, you can also submit your questions to the chat box. Our faculty may respond there, but there will also be frequent opportunities during the day to get your questions answered in real time verbally. So I want you to also know that we've reserved a big chunk of time at the end of the day for Q&A. And so you're welcome to stick around for that and speak to our experts. Please also use the chat box if you're having any technical issues during the day. Again, Sarah is monitoring that chat box and she will do her best to help you. If for some reason you lose connection with the Zoom window and have difficulty getting back in, you can email education at hccinstitute.org. And that does remind me, you are encouraged to please don't disconnect if you don't have to. If you need to step away from your computer for any reason, feel free, make sure you're on mute, turn your camera off, step away, but it makes it a little bit easier if you stay connected through the whole day so that our breakout assignments are as seamless as possible as we go through. You've probably noticed that this session is being recorded and registered participants will be able to view the recording in the HCCI Learning Hub. Hopefully yesterday you received an email from us with instructions for how to access your HCCI Learning account or to create one if you did not have one. If you have any questions about that, please email education at hccinstitute.org and we can help you. And that is also the place where you'll complete an evaluation and claim your CME credit. All right, so I did not advance through my slides here and I'll just remind you about our collaboration between HCCI and CAPSEA. And before I turn it over to Tom, we have one more interactive request for all of you. If you could go to the chat box now and I want you to type three things there. The first is your full name. I know we said just first name in your screen, but we want your full name in the chat box. And then also the full name of your organization, no acronyms there, please. And then your job role. That will just kind of help us get a sense of who's here. And we definitely look forward to working with you through the day. And so I'm very pleased now to turn it over to our faculty. Tom, can you go ahead and take it over from here? Great, thank you so much, Melissa. Hello, everyone. My name is Tom Valtieri-Reed. I'll be serving as faculty today with my colleagues. Introduce everybody in just a minute, just to reframe everybody's mind up as to kind of what we're here and what we're doing. So this Payment at Workshop is focusing on helping you all think through how to design and financially sustain a program, clinical services in the home. And I say all that because we know that the populations we're working with are complicated and where we are, our payment mechanisms and our operations, we're trying to find ways to connect them. And this workshop is very focused in on that. I have been at HealthCare for over 30 years, working with both payers and providers over the years. My colleague, Lynn Spraggans, who's also faculty today, and I work extensively with CAHPSI and with other organizations helping to design these programs. Today, Allison Silvers, Lynn Spraggans and I will be co-leading a lot of the content today. So I wanna start with those introductions. Allison, could you please introduce yourself as well as any background on CAHPSI that you wanted to share? Sure, thank you all. And let me also thank HCCI. CAHPSI is equally excited about collaborating on this. CAHPSI is the Center to Advance Palliative Care and we provide tools, training and technical assistance to make sure that all people living with serious illness, including their family members, get high quality care that aligns with what they care about. I am the Chief Healthcare Transformation Officer and I have had the privilege for about six years now of talking with a lot of private payers, staying on top of Medicare and Medicaid trends and talking with also a lot of population health and ACO leadership. So we'll try to infuse what we're learning from the other side of the fence into this today. Thank you, Allison. And my wonderful business partner, Lynn Spraggans, would you introduce yourself, please? You're on mute, I think right now, Lynn. There you go. So I'm Lynn Spraggans. I've been in healthcare for a little over 30 years, starting out as a business administrator for a large multi-specialty capitated medical group. And I've worked with the field of palliative care and with geriatrics for the last 22 years, working from a business background. I have a business training, but I've always worked on the side of partnering up with clinicians who are trying to find ways to deliver care that patients need that isn't necessarily reimbursed in the most obvious ways. And I think that connects us all here, which is we need to understand the business pieces we're working with and build forward to find a way to do the right thing. That's certainly what CAFSEE has done, and that's what we work on. And so my session later today is really about helping you think through strategically how to connect the dots between the services you wanna provide and the potential opportunities to make those financially sustainable. So glad to be with you. Wonderful, thank you, Lynn. So just to give everyone a little architecture for the day, the day is really broken out into sections. We'll go about 10 or 20 minutes with some content from the deck that you've received, and one of us will be providing the content. For some of the sections, we'll also then move into about eight to nine minutes of breakout groups. You're pre-broken out into groups. We just ask you that you'll go into a group if it's not the exact group each time. Our plan is to make everything the same, everyone's grouped together. We have bundled you together if you are coming as a group, as individuals, part of that same organization. And then one of us will actually be in there helping to moderate that time. But we'll have you go through some discussion questions to both help think through what you just learned, how it might apply to you, but also a really good opportunity to connect with each other. And so if you can find others in your small group to connect with over time, you might create a buddy over the next several years to help you through this journey together. So we're trying to create an environment almost as if we were in person as well. And then we'll move into about 20 minutes of time when we'll hear from our voices of experience. These are individuals, generous individuals who are sharing the experiences they've had in building payer-provider partnerships and having home-based programs. And they definitely probably have the bumps and bruises to show for that. So they'll share some of those. And so to that point, I wanna take a few minutes to introduce our wonderful Voices of Experience colleagues. If I could start with Laura Patel, if you could introduce yourself. Yes, hello everyone. I am Laura Patel. I'm the Chief Medical Officer with Transitions Life Care, which is a large nonprofit hospice and palliative care organization based in Raleigh. And we have kind of the full spectrum of hospice, home health, community-based palliative care, inpatient palliative care, and are looking at primary care as well. So I'm happy to be here and I'm sure we'll all learn a lot from each other today. Thanks, Laura. Laura brings that regional-based, built from a hospice organization into community-based programs. It's so wonderful to have her. Rebecca Ramsey, would you introduce yourself? Hi, yes, good morning, everyone. So nice to be here. My name is Rebecca Ramsey and I'm the CEO of House Call Providers in Portland, Oregon. We are a home-based medical practice that provides home-based primary care, community-based palliative care, and we run a hospice as well. Really looking forward to talking with you and learning more from all of the faculty and all of you, the participants. Thanks. Wonderful, and again, Rebecca brings that home-based primary care practice and a lot of organizational strategy that she's had to do in her role. Leanna Hoover. There we go. Well, good morning, everybody. Leanna Hoover, chief integration officer here with Gilchrest. We are based out of Baltimore, Maryland, and our services are hospice, elder medical care, which includes a couple of service lines, including geriatrics, home-based primary care practice, and palliative, both inpatient, outpatient, into that home-based practice as well. And happy for the opportunity to participate in your workshop today. Thank you, Leanna. And again, Leanna bringing some of that long-term care build out from there into community-based practices and also the administrative perspective based upon her role. And then Russell Kiefer. Good morning. Thanks for having me here. My name is Russell Kiefer. I'm with Providence Health. I am the senior executive director for palliative care for California, Oregon, and Washington. We represent, I'm part of a large health system that has inpatient palliative care programs, clinic-based sites, community-based sites, and have been particularly involved in the development and oversight of programming in the greater Los Angeles area. Wonderful, Russell. And again, a health system perspective grounded in, and also Russell's background as a social worker, so a disciplined perspective too. So from our wonderful voices of experience, we try to bring in a balanced perspectives and views for everyone. And another effort to help design this workshop similar to what it might be like in person, just wanna acknowledge something Melissa said is, we plan to end formally on time. As we get near the end, we'll talk about the fact we will have additional breakout groups. And so we'll break the voices of experience and faculty into rooms. And so you're happy to stay on for another longer period of time, almost as if you were at the conference and you wanted to go up to the speakers and ask them questions. We're trying to create that same experience at the end. So just wanted you to know that. So if you had certain questions as you hear folks talk today. If we could go into the agenda for a minute. Next slide. Oh, the disclosures are there. And then, so the agenda, so the morning is gonna be focused in on understanding value-based payments and what the world looks like that's different. Certainly an important part of this is building strategic relationships. So we'll spend some time there and then talking about those business principles as Lynn mentioned. I want to acknowledge that at two o'clock East Coast time, it'll be late lunch for some of us. We'll be having a break for the Hawaii group. I guess that will be your breakfast time, but we wanted to acknowledge that we'll have a good 30 minute break at around two o'clock Eastern for 30 minutes. And then we are gonna be doing five minute breaks throughout. So there will be a chance for you to bust out and come back in. We are going through a lot of content. And as we heard kind of a spirit for today, and then we'll move into the main portion of all this. We do have a large group from a large audience of different folks. Our goal is to provide you enough content, tools, examples. We know everyone's starting at different places and different stages. Some may not completely feel applicable today. We have heard from many people that they hit a couple of nuggets today and it was later on they picked something else up. So really encourage you to think about how this might apply today versus tomorrow. And then the idea here is not to have you go back and figure out how to go negotiate a contract. A lot of this too is thinking through who do you need on your team? And Lynn mentioned that a little bit ago and we'll talk about it more is, who do you need on your team to help you do this effectively? For example, if you're in a large health system, you might wanna go back and connect with your contracting team. You'll be much smarter as you go back and have a conversation with them. So with all of that, we do wanna encourage you to get to know each other even as we go along. We wanted to move into the, before we jump quickly to end, wanted to pause and just take a minute. And we'd like to, if you go to the next slide, have everybody in the chat box, just would like you to say a share. You know, when you think about value-based payment, when you think about going to this home-based model and setting, what is one worry or challenge or piece of information that you hope to get out of today? Just to help guide us, we'll be reading through that a little bit. It'll guide some of our conversation, but I'd just like everyone just to take 20 seconds and just write into the chat box. And we're just gonna kind of pause and allow people to do that. And then you can even take a minute to read what others are posting. So you get a little flavor of what others are thinking about today. So we'll go ahead and have folks post that. All right, so just reading through these, it's a wonderful mix of what we hope to hit on today, which is this mix of restructuring payment models all the way into how do we actually operate and figure out staffing. So a lot of today's concepts are going to hopefully sync up with most of those and really would help people would, you know, as we go through the day, if you've got specific questions, but we'll keep reading through that. Thank you all so much. We are going to go to the very first section. And in this section, Allison, I just want to point you to on the front of each of the slides for each of the sections, we have a list of tools. Those tools are available for you out there to go and review afterwards, if you haven't already. We're not going to go through each of those tools on this in each sections, we're going to give you the main content, but did want to acknowledge, for example, we have a wonderful tool on payment arrangement options that have been developed and key contract provisions, and also a wonderful tool that HCCI just developed on key metrics for demonstrating value. But with all that, I'm going to turn it over to my colleague, Allison. And Allison, you've got 15 minutes. Okay, I'm going to fly. Thank you, Tom. Next slide, please. So with this idea, as you can tell, we're spending a lot of time grounding, and I know there's a mix of us, but I want to ground us all on what is value based payment to start with some basics. And really, what value based payment is, is that quality becomes a part of the calculus that determines how a provider is paid, especially quality as it relates to cost. And spending often comes into play as well. I also wanted to ground and just remind folks that value based payment is not quote unquote alternative payment, that value based payment covers a wide range of payment models. As Tom called out, we listed them in the payment arrangements options guide, but it's often built on a fee for service chassis and adjustments get included in how payment works. Next slide, please. So to that point, as you know, fee for service, you get paid for each encounter and to generate more revenue, you provide more services. So what I suspect a lot of you are struggling with, and we'll visit this with our voices of experience in a minute, is that you've got this fee for service incentive and need for new services, but you're also being judged on spending and quality outcomes where your bonuses and your penalties get applied. And sometimes there's also what's called quality gateways. So in order to even get that bonus, you have to demonstrate a certain level of performance. On the other hand, there's growing opportunities for fixed payment. We heard a lot in the early days of the pandemic when healthcare was shutting down that the folks that were getting capitation were able to sustain themselves a lot more easily. One of the more common ways is through a bundled payment per enrolled member per month. Sometimes you might hear per member per month, but you get a fixed payment and regardless of how many services you provide, you have the same income. But of course, your performance is being judged again. There are often opportunities just as in fee for service on a fixed payment, you can get bonuses and penalties based on your performance. Next slide, please. So when I say judged on your performance, we put together here a common list of measures that are included for home-based care providers. Hospital admissions is sort of the big gorilla in what people are being judged on. Sometimes it's readmissions rates, sometimes it's adjusted for preventable admission rates. It's very commonly used. Same thing, emergency department visits are something that you can expect to be judged on. Patient satisfaction isn't used as often as I would like to see it, but it is a growing area and patient reported outcomes is also a very important area. For those who are responsible for their own case finding, patient engagement rates, some partners are looking at the hospice transition and how well hospice is being utilized. There's also this new concept called days at home, which really does account for that hospital admissions, but looking at on a particular period of time, how often the patient is outside of their home environment. I will say across all of these, please remember that they are very commonly able to be negotiated. Maybe not with public players like Medicare, but with private payers, they're expecting these to be negotiated. And remember, the population that you serve is really pretty high need. So your resource use is going to be high. Keep that in mind. And actually, next slide. I wanted to give an example, and I think someone put in the chat they're participating in the primary care first model. So just as an example to pull together these concepts, it's a great example of how fee for service, fixed payment, gateways, performance bonuses, it's the kitchen sink in this. And I know this slide is very confusing, but the point is that for participating providers, they do get a monthly payment. They're calling it the population-based payment. They also do have some service volume incentive built in that there is additional revenue for each visit that's done. Then they look at how well you're performing, and if you are performing at least the ground level, you can then be eligible for positive adjustments. In this case, if you're performing below it, you could be subject to penalties. Next slide, please. And I want to talk about, like I said, the big gorilla is hospital utilization. This might be a duh point for some, but it's worth spending a moment. If a patient is admitted to a hospital, it is not a failure. There is no expectation that your hospital admissions are going to be zero. And again, with the high need complex population, there's built into all these performance expectations and cost spending expectations that hospitalization will be used. So I know I worked for an organization, we were under bundled payment, and every time a patient went to the hospital, it was like, crisis, we did something wrong. Never stint on care. If someone needs to go into the hospital and that's what they want, please make sure. And they can. What these value-based incentives are driving towards is the too many. When you look across a population, if you have 100 patients on service and every month there's 100 hospital admissions, yes, that's an indicator that there's room for performance improvement. So, again, maybe a simplistic point, but really important, don't hold back when someone needs to be admitted in the hospital. It's built into all these models. Next slide. Just a reminder that especially with private relationships, it's a lot more than your payment parameters that get into the contract. Who's responsible for enrollment and disenrollment and how does that happen? Often the contract includes a lot about how they expect your program to function and what kind of credentials your staff have to have. I want to call out term and termination. Tom certainly said this a million times. I got burned in the past with a contract that did not have a favorable termination clause. So just a plug to remember to look at the termination and the other provisions. Next slide, please. So I wanted to take a minute. What we were hearing a lot and I saw it come up in the chat as well is this foot into canoes. You're living in fee-for-service, you're pursuing value. You probably have a contract that's a fixed payment, but you're still billing Medicare. So some thoughts about how you might go around balancing that. Tom, I'll turn it to you to call on the right people. Yeah, that's wonderful. Thank you, Allison. Again, encourage folks to put some questions or thoughts in the chat. What we're going to do now is spend a few minutes hearing from our voices of experience. It might prompt some more questions. Happy to grab those as we go as well, too. So I think to your point, this two canoes, there's this issue of how do you manage the practice when you've got a couple different types of revenue streams coming in? And Rebecca, I'm wondering if you might start and describe the work you've done to try to figure out the right performance and or productivity metrics that you use in your practices and with your care teams when you're operating in both payment models. Sure. I'm going to talk just a little bit briefly about our home-based primary care performance metrics and how we think about this idea of having in home-based primary care, we actually have a variety of contract types, fee-for-service, fully capitated, and then a blend of both. And so I think the main point is that when you move to a capitation or per member per month payment structure, the number of visits that your team perform become less important to your overall revenue than the number of patients you actually panel on their panel. So we've found it really helpful also to communicate with our providers and our teams that a panel size expectation is a team metric rather than just a provider metric. So as an example, we track for our primary care providers, their monthly productivity dashboard has four primary metrics on it. We look at average visits per day. We look at the number of patients on their panel. We look at the number of new patients that they intake in a period of time and the number of charts that are not closed at the end of the month. And that's because those are all relatively important components to the way that we're looking at bringing in revenue and our ability to care for a patient population. So those are the financial metrics. I can talk more about the quality metrics. We're obviously looking very carefully at our quality metrics and all of our contracts have some level of a quality bonus on top of that. Rebecca, I think that's so helpful. Just a couple of points and we'll pull these seeds out as we go along. But I think there's one thing just to set the frame for everyone that you are working under a variety of payment models. And I think that's an important concept that thinking then how does that impact the team? Because you're not going to necessarily do something different and shift the team around. Oh, that's this kind of payer. We got to do this. You're trying to make consistency and you're doing it at the market level or at the payment level, I'm sorry, at the metric level. And also the concept of having a panel, which primary care practices, that's a common thing. For others, it's a new concept. But could you describe just a little bit further when you think about panel and team based, what are some numbers and metrics you think for the team as you work in these different payment models? Yeah. So, concretely, in our primary, in our home-based primary care program, each provider has a panel that's around 150 patients. It varies depending on geography and acuity, but around 150 patients. And their team is comprised of themselves, a primary care provider, a nurse, a social worker, and part of a chaplain. So that's our team-based model. So that group of people, what we're looking at is how are the patient's quality metrics in that panel looking, and what is our sort of revenue per patient and patient touches looking like? So we stratify the patients in the panel, and that allows us to know for a certain type of patient, we're probably going to have the entire team visiting over the course of a six to eight-week period. Sometimes our patients are going to need a visit every week. Sometimes they need visits, you know, once per two months. So we have a stratification tool that allows us to kind of look at what is the appropriate resource use based on the patient's acuity, and that gets, they get re-stratified often. So anytime health status changes, we re-stratify them, and at least every six months, depending on, you know, on what's going on. So if they end up in the hospital, we're going to, we're going to obviously increase resource use across the team. That's great. And I, Ray acknowledged, made a comment in the chat that, you know, this, even in the fixed payment, it could incentivize a different number of visits based upon your panel size. So really trying to play very closely to what's that right mix of panel size for the acuity of patients, et cetera, is a really important part to that, and adjusting your team to that concept is important. I want to shift over to Laura for a minute, and, you know, Laura, you have talked about how you've used different non-billable clinicians to optimize care across the different models as well, too. I'm just wondering if you might share how you're utilizing team members across the different payment models. Yeah, so right now we have a community-based palliative care program where we see patients at home and in assisted livings and nursing facilities. And so we primarily, for the most part, operate, you know, the vast majority is still fee-for-service, and we have some patients who fall under some contracts that we've been able to develop with some different plans. And we have been able to incorporate nurses, social work, and chaplain to help support those teams. So we really, what we've been trying to do is, you know, utilize our nurses early on after the referral, making that first phone call, really understanding what's going on, because what we found was that sometimes, A, there'd be a delay to get our MP out there because of scheduling, and then something would happen to that patient and they would never make it to us. Or our MP would go out to the home and the patient wouldn't be there, or they would be like, why are you here? I don't want you here. Or they really just needed hospice, because we are a hospice, so we do get some referrals to us that, you know, really need to go to hospice. So that initial phone call has been very helpful to really understand what's going on. And a lot of, you know, a good percentage of those patients after that conversation are actually able to be directly connected to hospice services, which is really what they need for some of those patients. So instead of going through this kind of couple-week process, that may delay their care. So that's been really helpful. And then we also have the nurses do med reviews for some folks, you know, by phone to get that initial list down, because that's very, you know, an important part of what the nurse practitioner is doing, but it kind of helps get the ball rolling for some of that. So I think those were kind of two of the key points is really, you know, decreasing delays to the right level of care. So if they need hospice, they should go to hospice and we should figure that out, you know, early before a delay in sending an MP out. And then also from an efficiency standpoint, you know, we don't really like to send our providers out to empty houses or to people who don't want us to be there. So really making sure that people understand what we're able to provide and why we're coming so that when we come, they're ready to accept us. And then we also use more of the nurse social work model for some of our bundle payment models. And we have a heart failure program. We have a program with a Medicare Advantage plan. And we are at the tail end of participating in the Medicare Care Choices model, which is ending, but which we housed under our community-based practice. And so we're able to kind of utilize and get comfortable and more familiar with that, that sort of per member per month payment and how to structure visits within that. Laura, can I ask, it sounds like the nurse social work model, you have a different staffing model for when you're under a fixed payment versus when you're under fee-for-service, is that? Yeah, I think, you know, primarily with the fee-for-service, we are more heavily using the nurse practitioners and physicians, especially for, you know, initial visits and for the bundle payments, we are still using those services. There's still physicians and nurse practitioners involved. It's just that the nurse and or the social worker would take more of the lead in terms of case managing and sort of being the primary person for that patient and family. And if I'm reading Tina's question in the chat correctly, so it sounds like that first call you're doing for both fee-for-service as well as your fixed payment because you're finding it's an efficient way to get the billable visits to the right patients as well. So it's essentially, it's a cost savings initiative within the program. So we're trying to reduce the amount of lost revenue by, you know, having patients who don't want us there or who aren't there. And, you know, it's a lot, we cover, you know, an eight county area, we have a lot of rural areas. And so sending a nurse practitioner out, driving for 50 minutes and then, you know, driving back, you lose a lot of, you know, they could potentially be seeing another patient at that time. So not only for access issues, wanting people to, you know, we only have so many resources. And so we wanna make sure that we're getting out to people in a timely way and that's part of it as well. Yeah. So that was a really, and we're gonna hit some of these topics as we go forward as well too. We'll hear it in the operational sections particularly in the afternoon about how best to optimize the team. I was just gonna wonder too, just to shift gears a smidge with Russell and then Rebecca, I'll circle back to you if you had some additional comments. But Russell, I think from a health system perspective, you've shared ahead of time that there was some challenges you all have had in actually weaning yourself off of some different types of payment models and even different referral sources as you moved into your value-based payment models. And so that transition, I was just wondering, could you share your insights or a quick story that you had on that transition between fee-for-service to a value-based? Sure, I would, to be fully transparent, we're still living that dream. So we're in the middle of it. We also represent a pretty wide payer mix in our contract agreements. So I would say one unique aspect of our programmatic development going back to 2015 is that we were heavily, heavily grant funded initially. And so we built out a program that served a lot of unfunded and underfunded patients. So at the end of that three-year grant cycle, and this may be really unique to us, we had some referral sources that were pretty hardwired. So shifting from that model into a revenue producing financially sustainable, it's a matter of a good payer mix and it's been gradual. So at the end of the three years, we didn't say, all right, we're not accepting these patients anymore. But over the course of time, we've had to get clearer and clearer for ourselves, even kind of what the breakeven is and how many of those patients we can serve on our program. And then to Laura's point, I think looking at if we do accept those patients, realistically, what will that look like as we try to balance what we're accountable to with some of our value-based agreements? Because the expectations and the accountability to the outcomes in those arrangements really keep the lights on for the other, allow us to serve the other patients. That make sense? Russell, thank you. I think that whole transition experience that people might feel at micro levels and macro levels, your point is the journey is still going for you. Yeah, I would say if we had the foresight to be able to think four years ahead, hindsight, of course, is 2020, but that was so early in the landscape of home-based palliative care that we were just kind of living day by day at the time. Yeah. Leanna, from your perspective, any thoughts or insights you would share as you've heard the conversation in your own experience in this two canoes challenge? Yeah, the only thing I would add is, it's finding the balance of, do you change? For example, we heard Laura talk a little bit about a different model and execution of care and the composition of the team, and again, all learning. For us, our home-based primary practice, certainly fee-for-service, and we're also able to participate with the Maryland primary care value-based model, but essentially multidisciplinary team, care planning, execution with social work, and meeting some metrics that they have established. But for us, with our panel size a little over 500, and not all of our panel is attributed in both canoes, if you will, but we then decided to take the same approach and apply it regarding the care that we were executing for the panel to still meet both fee-for-service and that value-based metric. Great. So during this discussion, we've had a lot of chat going on on the side. I think people are seeing that, you know, people are trying to respond back to questions as they go, but certainly maybe we'll just load one more question to the group here. I think the question just came through, different considerations on panel size for providers when doing both home-based primary and palliative care. I don't know, Rebecca, do you have a perspective of that or Laura, one of you? Laura may be the better person to answer just because our community-based palliative care program is actually a wraparound model. So we're not using traditional NPs. We're basically, we have a nurse social work and an outreach worker model, and we take care of a safety net population. So all Medicaid or dually eligible recipients. So in that model, they're attending is actually, you know, a specialist or a primary care provider in the community, and we're basically doing a wraparound model. So we do have quite different metrics and panel size expectations for that group. It's much smaller. I mean, you know, 20 to 24 patients per team is what we run in our palliative care model. Great. And again, when we think about today's workshop too, we are talking about highly complex patients and whether it's primary or palliative care, the interdisciplinary team components, the element of the complexities you're dealing with, maybe just scope of practice if you have primary versus palliative, but the population is still highly complex. Laura, any comment from you on the, you know, managing your teams differently based upon what the panel is that you're managing? Yeah, I mean, I think for a while we, when we were smaller, we had our MPs in the field were actually doing both palliative care and they were in hospice. So they were serving as attending for hospice patients as well, particularly in our rural areas, but we don't, we currently don't have primary care. So they're not having a mixed panel with primary and palliative. And when we do move into that, it probably will be somewhat different teams and not necessarily a mixed case model. We've moved away from the mixed case model on the palliative care and hospice side as we've grown and have been able to do that, but it does make it a little more complicated. Yep. One last question and then we're gonna stay on track and keep moving to our next section. And today we're gonna clip right along, but there was a good question about chaplaincy services and how you might fund or get services in chaplaincy. And I don't know, Russell, do you have a perspective of how you've done that that you could share? Yes, I do. Again, we're very much in the middle of that process. I think being part of a larger health system, we've had the advantage of being able to tap into some of the greater infrastructure that is the hospice and the hospital system. So for many years, we have borrowed chaplain support. I don't think that's ideal. And there are certainly, we kind of keep a spreadsheet of those encounters that we're not really capturing in the electronic health record or that aren't data points that are searchable, but kind of wins. And we have several instances where chaplain support was really instrumental in the care to the patient and that it was primary in some situations. So obviously as a religious affiliated health organization, we are very, we value the voice of the chaplain in spiritual health. So only recently have we moved in, here we are six years into our program where we've been able to add a few dedicated chaplains. So from a financial standpoint, I will say it's a big challenge and we are also lucky to have some support through philanthropy. Great. Can I also add chaplains is often the one that gets noted that especially in a fee-for-service system, it's hard to get the revenue stream for it. But I wanna pick up Russell, you were saying there is patients that benefit significantly from the chaplain. And I will also say when we were joint commission certified in late 2019, there was a big focus on spiritual care support in our service. Right. And that makes a lot of sense. I'll just also add economically, if that's what the patient needs and you're delivering that and your outcomes show for it, there's economic value that you can capture or point to that would justify getting revenue for the entire program, not specific to the chaplain. Wonderful discussion. Thank you all. We are gonna move on to the next portion, the next topic. Continue to encourage you to send questions and chat on the side. So we are gonna move into the portion around leadership skills, around building strategic relationships. And based upon where we are in our delivery system and our payment models, this does start with having relationships. We have got a series of tools for you also around, for example, an opportunity assessment and some tips too about how to maybe respond to stakeholders when you approach them when they might not have the ideal response for you. What are some ways to think about responding to those? So Alison and I are gonna tag team that, I'll do a couple of slides and then we'll get into the data a little bit further. So going into our first slide on this one, we just wanna acknowledge that this opportunity assessment, this portion about building strategic relationships is a process, it is ongoing, it's forever happening. So it's not a one-time event. And it starts with taking the time to really understand if you're trying to find a financial partner, you're trying to find someone who's willing to pay you for some services and you really need to spend time understanding what the problems are that they are trying to solve. And Alison will go through a little bit to think through some data sources that are out there, but partnering with someone that has access to a lot of information about payers or hospitals in your market can be very, very helpful and important. But that's the first step as you're doing that. And then you're taking that all in and you're thinking through, okay, what can I offer? What do I have in my services that can help meet those needs? And then you move into the side of prioritizing and saying, okay, I can do this and this is where I should set my resources, where I should spend my time and then prioritizing even which partners to go into. We'll talk about that in a minute. And then you're cycling through again. And so this is an experience, it's a process, it's not a one-time event is what we really want to emphasize and the fact that this has a lot to do with understanding your customers. And in that example, I often, in my consulting work, I'll say to someone, you're gonna bring a solution to someone for a problem that they didn't know that they had and we're trying to flip that around. You wanna understand their problem and how you can fit into that solution. So the next slide just brings us through a discussion around who are potential financial partners. And we've got three broad categories. There's certainly the traditional ones and health plans and you're asking yourself, who's paying me today? Where is my volume coming from? That does not mean that you go and work necessarily with the largest payer in your region. You might go with the one that is the smaller or more nimble one or the one that might be very connected to you because you are both regional community practices or organizations working together. So, but understanding who your current health plan payers are and recognizing too that not all payers are the same. There's Medicaid, there's Medicare Advantage, there's different types of payers. And even within one organization that might be one branded name, there are many, many different divisions and different sectors within. So just recognizing that you have to understand who those players are. The second bucket is certainly if you're a community-based practice, you can partner with an ACO or a health system. And again, really understanding where are you getting a lot of referrals today for one of your, if you're starting new, where are you getting a lot of referrals from hospice today? And is there an opportunity to open up a conversation or a dialogue around other services that you can do for them? And then the third bucket is, I would describe as a bit of an emerging area, right? So there's some new entrants coming into our markets that have solved this issue of matching up and marrying up providers and payers. And so some of them, they're taking on risk themselves or they're working through the contract process of taking on risk and building on networks. And so if you're a practice looking to contract, you might contract through one of those mechanisms. And that is certainly another solution that's evolving over time. But part of it all really goes back to, again, stratifying and understanding who it is that you could partner with, being open to who those partnerships might be and how you might work with them differently than you might have in the past. And in some cases, kind of readjusting your own perspective of what you've been. Because in a fee-for-service world, they've acted a certain way. And in a value-based world, you're gonna really define a new relationship with them. We're gonna spend some time now, Allison's gonna dig into looking at what publicly available data is out there and I'll hand it over to Allison for a few slides. Thank you. Next slide, please. So I'm gonna start with Medicare Advantage. A lot of times for home-based care, this is the natural and it's natural, both because of the populations you're serving, but also there's a lot of conversations going on in Medicare Advantage about bringing home based care to their members. And I will acknowledge that big kahunas out there, United, Anthem, Aetna, are looking for broad solutions but I've heard them all say, like United's a great example. They do have a lot of national solutions available to them, but they equally are interested in working with local organizations providers that could meet needs nimbly and and get to additional members of theirs in need so I wouldn't dismiss. Oh United's too big. Remember your local ones. And in terms of where to find them. I actually recommend doing the same thing that consumers do going to medicare.gov and putting in your zip code or taking a look, because there's a lot of good information about the plans and you can see how they're scoring. And you can see maybe where having home based care could make improvements for some of their scores. Also looking at the dual eligibles, it's a natural for our populations. And then the special initiatives might be hard to find. But once you come up with a name you might want to do a Google search check out their websites and see what's going on. There's a couple of other places the Home Health Care Cost Institute and Kaiser State Health Facts have public reports on MA penetration by county and who's in the area what kind of enrollments they have. And on the commercial side, your State Department of Insurance is a trove of information and beyond what Medicare reports out the State Department of Insurance often produces its own quality reports. So the slam dunk would be a Medicare Advantage plan that maybe has a higher proportion of complex patients on their quality measures show somewhere for improvement, that would be the slam dunk. Next slide. Medicaid. I know there are some states I'm suspecting we have our Hawaii participants here because Medicaid is now getting into the game of home based care. There's, this is a slide of where Medicaid plans are so yes acknowledging the diversity in our audience, you might not have this available to you. The good thing about Medicaid plans is, I would say on the whole, they're a little behind their Medicare colleagues. So the idea of home based care might be new and exciting and they haven't covered ground with national vendors. The other thing about Medicaid plans is you're going to start getting a lot more of that mix of the local providers and community based organizations who run Medicaid plans, and that mission alignment might be a really nice place to start conversations. Next slide please. So, there's also a host of providers, not only our home based providers pursuing value based payment, everybody is looking at it, obviously a broad spectrum. But to take a look, the Center for Medicare and Medicaid Innovation posts everything publicly, innovation.cms.gov, you can look through your state, or if you have a particular interest in say oncology models, you could look for the model and see who's participating in your area. Next slide please. And on that, I just wanted to make some suggestions. Accountable care organizations, in theory, have aligned incentives. I think we'll be hearing from the voices of experience. Accountable care organizations have it hard, especially if they're run out of hospitals because the incentives conflict, often, but certainly finding the right person at an ACO could open up a conversation about how you can add some value. The new direct contracting entities are publicly available on the innovation website. I think maybe actually one or two of our registrants here are direct participants so our afternoon session, we'll get into some details there but if you're not participating, you can add some real value to them. And of course the primary care first that I went through has the same incentives. I mentioned oncology. ESRD, there is a lot of attention on ESRD populations and home-based care for ESRD populations. Even just having a few good conversations about treatment options and how to manage symptoms could be really valuable there. Hospital at home, and I think some of you might be running hospital at home programs, but even if you're not, they're going to need somewhere to discharge and it's increasingly apparent that if you're eligible for hospital at home, discharging you to the traditional care system might not be in the patient and family's best interest. Next slide please. And last, I did want to acknowledge that what's available, here's just an example of ACOs and what your choices are vary tremendously. But I did want to put in a plug for those who might be in a geographic area where your natural options might not be enormous to think creatively. We had a past accelerator participant in Montana, who actually she was running a great program. She approached local VA and wound up forming a really nice financial partnership with the local VA. So just a suggestion that if your options are slim to still look around at the providers that are there and you can probably find some mutual interest. Next slide. So what is that mutual interest? Click all the way through. Of course, as we've talked about, they're going to have their own performance and quality metrics and yes, probably most likely their performance and quality metrics are going to be about the use of hospitals, the use of EDs, patient satisfaction, the same ones, if you have a direct contract. So what you can do is extend their services, making sure that you're getting into the home, concentrating on their high risk ones. So the ones that they're most worried are going to throw off their metrics, you could help provide that added layer of support. Some value based providers are trying to get to the right geographic coverage or patients so that they could be more attractive for their contracts and you can add value there. This last one, we created these slides a long time ago, but now I think this is probably one of the best ways that you can help other value based driven organizations is paying attention to clinician satisfaction. Burnout and distress is through the roof, as I'm sure within your own programs you're experiencing that. And to have a resource that can help with the high risk patients, that can help navigate some of the more difficult treatment decisions, to give them the comfort that they know that their high risk patients are getting the care they need, actually is proving to make a difference with clinician satisfaction, reducing burnout. So please don't forget that you're adding value that way. Next slide. And here's some other things that you may not think are apparent. The go to is, oh, I provide home based care and I prevent crises that could have somebody wind up in the hospital. But you can also really do a great assessment that has revenue implications, especially for Medicare Advantage plans. Now I will say that this is getting a lot of blowback in the press. But for right now, the opportunity to really document what's going on with patients and what their problem lists are has revenue implications. Fall prevention for Medicare Advantage stars is an important value add. Vaccination rates is an important value add. And all the things that you do with medication management is measured for not only MA plans, but all health plans and a lot of, increasingly a lot of providers as well. Next slide. Thomas. Yeah, this is me. So I'm going to, we're going to kind of round out the section, thinking about, you know, how do you, you've got data, you've got yourself armed with what you got, how do you begin to approach and get in the mindset of your partners. And I, you know, we want to acknowledge a couple things. For example, in this one, you know, partnership with a hospital system, it has its challenges. You know, our hospital based system still think about number of patients and occupancy rates. And so you have to be thinking about how you reposition what you're doing that helps solve some of their problems. I thought, one of Bridget's comments, like how do you align your goals with the system, she mentioned that earlier on, and this is it, like how do you think about connecting what you're solving, for example, they've got admissions that they could have shorter length of stay, if they had a good solution to send someone safely to home with that would help give them the support they needed at home, targeting those patients that actually are some studies on, you know, the DRG revenue that drives a lot of hospitals and how can you help solve margin issues for hospitals. So just wanted you to get, you know, that as an example in your mind as to, as you're approaching these places, they are going to come in with a certain mindset, but don't assume that and work through some of those questions to think through how you can creatively help them. Next slide please. As you think about moving into, again, a conversation with someone, you know, being prepared to talk about and you know we say the word debate, obviously the idea is not to have a contentious conversation with someone but you might find yourself trying to defend and things like that and really stepping back and thinking about open ended questions that help address and get to the core issues and core problems, but having good information about your own program is very, very helpful. That could be very pragmatic process oriented. How many patients, do you see how long do you follow them. What is your response rate and turnaround rate. How many of them have advanced care planning or goals or care documentation. Those things are also valued as well as how many calls do you get on a weekend, because that also, you know, can help infer potentially how many admissions have been lost. So really thinking about that and there's a lot of publicly available data as well too. So preparing yourself to think about how the studies and how your data and how your work feeds into what they're trying to solve for. Next slide please. So, making the initial contact a lot of times we get asked like how do you even find somebody in a health plan or how do you find someone in the ACO and, and our voices of experience will go through some examples after our breakout groups but you know finding someone but I think two pragmatic ends, you know, one is, you might have a case manager group that you work with today on a regular basis at a health plan or an ACO or someplace and how do you sit down and talk to them about these common patients that you're seeing and you're seeing, and you can start to build a relationship through a clinical channel. The other in a very strategic way is thinking about your boards and board of directors and who is on your board for example if your community based practice, and as it makes sense to invite someone from a local health system or maybe a medical director from a local health plan, just to begin to build relationships and understand the other people's perspective so there's very strategic ways to think about those relationships. And then the, this last slide is just to acknowledge on the next slide is to acknowledge, you know, what's a good thing to have ready going into a conversation. And again, going back to my point earlier like you want to walk in with, I got the solution here's how much it costs and pay me. This is about building a relationship and so using a good patient story sometimes can help set the context for what it is and what the nuances what you might be delivering versus what other services might be stats on the population you serve as I mentioned that any quality improvement utilization efforts that you're doing your team composition, you know, if you look at guidelines related to supporting those a serious illness, specifically the NCP guidelines on quality palliative care, you know they specifically talk about eight domains of quality care and how do you align with those. And so that is an element of how you could bring that information in, and sometimes it's good to open up with an idea around a pilot, and that you're thinking about, you know, for some organizations. It's too big to think of a big project Hey, maybe we could start with this region with this population where are you struggling the most and let's let's work out something over the next nine to 18 months and see where it goes so there's a lot building that relationship and just having a conversation, and you'll have them a couple different times and over and over our voices of experience will go through that. Before we go to breakouts I just want to pause Allison do you want to add a comment or observation. Yeah, just a quick color comment on that pilot. There's really a lot of evidence around decision making and offering anyone a trial period, let's just see what happens is a powerful way to get something going. So even if you just say, you know, I think we can add value, I under I hear your skepticism. Let's try let's let's do five patients 10 patients and see what happens. It doesn't even have to be something formal but really getting that foot in the door and just a level it's your chance to prove yourself your audition almost. I really did want to encourage folks to do that. Great. So we're going to go into our first breakout. It is 37 after the hour right now, we're going to come back at that 49. How's that 40 after the hour 48 after the hour we're going to go about 10 minutes or so but what we want to do is give you all a chance you're going to go into your breakout groups, one of the faculty or voices of experience will be in the room with you. Their role is to help prompt discussion and have folks jumping right in and sharing. When you go to share. We're not going to probably make it around to everybody in the breakout rooms if you do that's great but certainly introducing yourself but sharing a question that we want to have folks share with each other here is, you know, have you experienced any roadblocks and finding a good partner. What are the reasons for those roadblocks. And what are some ideas you have for moving forward so part of this is learning from each other what have we tried what haven't we tried, and also part of this is just getting to know each other and having some chemistry within the groups. So with that, we're going to and you'll get an alert. I believe right, Melissa. 60 seconds before you'll then be just yanked right back in if those have not been on on these rooms but you'll just be pulled right back in and your conversation will be cut right off. Anyway, so go ahead and you can go ahead and queue us up to move into our breakout rooms and we'll see everybody back here at about 48 after or 49 after. Hello, all. Welcome back. For those of you that might have run into it too, we had a good discussion going and then the time clipped us right back in. So, Jason, thanks for sharing in our group. I'll say that. We'll all be back together again on the next group, next breakout group. Do we have everybody back in the room? Looks like we do. Good. And again, the spirit of the breakout rooms are to give you a chance to kind of hear a little bit from each other. So we're going to try to keep you together. We may do a couple moves around during the day just for those that might want to have matched up with their own group. So just wanted to acknowledge that. But our idea was to keep that pretty consistent so you guys can all learn from each other and also to break it up a little bit for everybody. I want to shift now to our voices of experience in all of this and definitely encourage folks to please continue to put information up in the chat, share any experiences that you've been having. But in this portion, we want to hear about the journeys that our voices of experience colleagues have had and what they've learned. So I'd like to start with Laura in this one. Laura, you had a journey around approaching a Medicare Advantage plan and how you kind of kept that relationship alive. So I was wondering if you might take a few minutes to share your experience. Yeah, I think, you know, so a new group came into our region. This was probably like six years ago, and I was able to connect with their chief medical officer, senior medical officer, start some discussion about palliative care. And he was taking care of a very complex population, very sick, multiple needs. And he initially was very excited about, you know, these opportunities, maybe we could figure out a way to work together and then kind of got the kibosh from, I think, his higher ups, because their care model, he's kind of part of this care model who's also managing an MA plan population. And so the idea, the thought was, well, you're, that's kind of what you're supposed to do already. So we don't really need palliative care. And then about a year, so I did some education with them and his staff and just sort of what is palliative care, what is hospice, sort of some general principled stuff. And then about a year later, after they had gotten some data and some experience and looked at, you know, what some of their outcomes were, he came knocking back at the door and saying, you know what, let's, let's look at this again. And let's think about it. We were able to work together to develop a pilot for a kind of bundled payment model using nurse social work and some nurse practitioner to support the highest risk patients in their population. And it was not a huge pilot, but it was consistent. And we still are active with them today. It's changed. We've had a little bit of evolution of the model. And they've had evolution as well in terms of their population and are now actually also in the direct contracting entity world. And so we're looking at, you know, how does, how can we incorporate this model into that population? So, you know, for us, it was, it's been, you know, we were able to work with them at a, you know, this is like I said, six years ago, five, six years ago, and able to learn a lot through the process and also get some data sharing. So that was, that relationship was really important to be able to, you know, have him be able to share their, their utilization data with us, which we had trouble getting access to at that point. And then as time has gone on, we actually have, as Tom mentioned, thinking strategically about, you know, your relationships, we have recruited him onto our board of directors. And he's continued to be really active in our organization. So, you know, that for us, the core relationship was really at that clinical level between me and the chief medical officer. And I found that with several of the payer conversations that I've been involved with, trying to connect directly with that, that medical leader within their group has been pretty successful, at least at moving us forward and getting steps, you know, to get to the next step, it doesn't always work out. This one was the, you know, probably our best success in terms of, you know, longevity, and being able to get some data to really then use that to go to approach other payers and say, this is the impact that we've been able to have on utilization and hospitalizations and things like that. So it's really persistence and kind of sticking with it. That's great. And I just want to kind of feed some information from our small group discussion too. We were talking about in COVID right now, there's been a lot of, you know, well, resources aren't here, we've got to focus here. And so health systems and others have really been struggling about investing in something new. And Lynn was sharing a good example of, you know, thinking about the front door of the hospital and the ED, and is there a pilot places you could do to catch patients early on and how could you interact with them differently? And Laura, your experience was, you know, just, you're always kind of finding those relationships and then floating different ideas and nuances out there to see where it makes sense. And not, you know, there's been a lot that everyone's been adjusting to during COVID, but there are still opportunities to be thinking about. So I wanted to shift a little bit, and Leanna, I was going to see if you might share, I think there's a piece that we've talked a lot about data and about strategic relationships and using information. And I know you've got an experience of what you've been doing in your state, using and leveraging publicly available data, but would you mind sharing how you've done that and how that's fed into some of your relationships and strategic partnerships? Sure. So the state of Maryland, we use a health exchange, information exchange, and it's called CRISP. And the majority of health entities really participate with that, which is looking at claims-based information. And when we launched, we really needed to have the buy-in of our own healthcare system. So we operate under the umbrella of Greater Baltimore Medical Center. And what CRISP was able to demonstrate for us was at time of enrollment into our program, that really became the intervention. And it would take a snapshot of outcomes sequentially. So at a one month, a three month, a six month, and a 12 month timeframe. And ultimately what we were able to do was certainly demonstrate the decrease of utilization, readmissions, ED, observation. And over the course of time, we were averaging approximately a $14,000 saving per member enrolled in our panel. What was nice about it, it was very, right, it's neutral. It was very objective. You know, the information is hard to question. And so that really grew the buy-in and demonstrated that return on investment to our own internal healthcare system. We became a little bit more savvy about how to utilize that information as well. One was as we grew, and we also started to see our length of stay within our program expand, sorry for the noise. We wanted to use that measure to make sure we weren't also having dilution in our outcomes. So as our panel got larger, we would kind of double check and want to run that every so often and make sure, are we seeing any decrease with that savings that we had been able to demonstrate? And if we were, was that a cue to us as an opportunity, then are we really looking at opportunities for transition off of our home-based practice, maybe into, you know, it's time to have the conversation again with social work and goals of care and maybe that hospice transition. And the other area that we've utilized that information is, again, strategic partners. Using our marketing team, business developing within hospice, and we were starting to learn about if we were to layer, we have a tied up team in skilled nursing facilities and demonstrate that with discharges from a certain healthcare system or even skilled nursing facilities we were working with, we could say, hey, if you have both of these partners in your community, look at the outcomes that you're able to achieve. So that was another kind of strategic way that we were utilizing that information. And Leanne, if I could just ask you kind of a pragmatic question, when you think about that data, who did you typically present it to or is that a practical, how did you use it or where did you go with it? We, yes, depended on the audience. So for example, with our own healthcare system, you know, they're very familiar with the ACO and population health. So that really is where we started as far as in front of that quality team. And then we're invited, if you will, to expand to the higher leadership team of the C-suite to demonstrate those outcomes. And then similar with, for example, with the business development, we, with different, it was actually with Hopkins. You know, they work with care management, starting again with their managers, and then that the outcome spoke for themselves. So it helped to gain traction and gained us action or accessibility as far as their managers. Excellent. Thank you. I think that's just so much that how do you build that into your regular conversations too. And I love your language of, it was like objective information that, you know, you could roll anchor to. And then I was going to, we've got a few more minutes before we're going to do a break, by the way, at five after, before we go into the business planning side. So we will have a break in just a minute. Russell, I was wondering, you've, you know, these cycles of relationships might go back and forth and up and down, and you've had some experiences of a medical director that you've been working with. And just was wondering if you might share some strategies you've done to keep the relationship moving and help address some of their challenges. Where I am right now is actually trying to take a pretty mature and successful program in the greater LA area, and then replicate that in other service areas. So I know that that's different from a startup, although I think some of the same things apply, some same ideas apply. So specific to my situation, it's not only a medical group, but it's a whole, it's not only a medical director, but it's a group of physicians who have a vested interest in this project and where it's moving. And so in the interest of time, I kind of, I wrote down a couple of key ideas or principles that I have right now. So one is understand the lay of the land and what works in one geographical area may not be exactly replicable in another. Listen deeply to your stakeholders. Listen to understand not to respond. Leverage your data and your outcome measures if you have them. If you don't, then use what's out there that's been mentioned already today. Remember, you're not a noble doctor or nurse or administrator with a great idea. This work is established and evidence-based. When providing data or education, you may have to repeat yourself many times, and I have found myself giving the same, some version of the same presentation with similar data over the course of a year to a key group of people, but then new members each time with new questions each time. And also your new partners may want a level of control or oversight or expect a level of accountability that your current partners or relationships do not. Consider these. Consider what their involvement may look like and build into your relationship scheduled points of communication. I think, again, the mention of the pilot or proof of concept is great. We've had really good success with that. Excellent. It's that iterative process of going through these relationships, and to your point, your tips are really thinking about how to sustain them over time. Want to just pause for a couple minutes. Questions from folks. We've talked a lot about strategic partnerships. We've tried to have some balanced views from the voice of experience a little bit, but want to just make sure that we have a moment. So if you could chat in the chat box, we'd love to get a question, and we can direct that to voice of experience. Let me go to Rebecca. Do you have any reflections on this section on building these partnerships and particularly in your role and how you think about them? Yeah, we had a great breakout group discussion about this. I don't know that I have anything. I mean, I agree so wholeheartedly with what's been said, and I just would say that I'm currently in the process of trying to renegotiate a number of our contracts, our home-based primary care contracts with Medicare Advantage payers in our market, and I can't get anybody's attention right now. I mean, so just to sort of validate the struggle, you know, there's so much going on, and so I finally had a little bit of success by basically writing to my provider contract partner who had been sort of ignoring emails for months and months and saying, you know, hey, I know it's such a crazy time, and I just want to let you know that we are busting our butts to make sure that your members are getting COVID vaccines, those that can't get in the clinic. You know, we're working really hard, and, you know, we really need to be reimbursed for this care. We're not going to be able to continue to serve those members that are not able to get into your brick-and-mortar settings, and the next day I got, you know, not exactly the response I wanted, but let's set up a call, you know, and so it was, I don't know. It's like finding the message that's going to resonate in the moment seems to be, and then finding the right person. That's always tricky, and I think I really try and find, if I can't get anywhere, you know, with the contracting department, I really try and find a medical officer or a nursing officer or someone in the care management or population health realm because they're the ones that are having, you know, the clinical conversations about patients and the struggles they're having. Excellent. Oh, I'm sorry. I just want to chime in. I think you hit on perhaps accidentally, but my guess is your partner is being judged on their vaccination rates. So the fact that you offered that is just a beautiful illustration of understanding what the pain points of your partner are and translating what you do into how you solve their problem. Yeah. Well, I think you also demonstrated the importance of the mental model of polite persistence and polite persistence and having the concept so we're going to go into a break. We want to make sure that if you can do not leave the session because if you leave and you come back in the breakout group start to get a little bit flippy floppy on us so we just turn your camera off put you on mute. We're going to start back up again at 11 after. So you've got five minutes, and then we'll start back up at 11 after. Thank you all. All right, folks, welcome back. Hopefully you're well rested after your five minute break. We've got our wonderful colleague, Lynn Spraggins, that's gonna talk through the business planning principles and how to approach all this. I just wanna remind you again, in this section there are some wonderful tools out there, both a spreadsheet analytical tool as well as a companion guide to go along with it to help you think through some of those questions. And we're gonna go, this will bring us all the way up until our full break at the top of the hour. And with that, I'm gonna turn it over to Lynn. Thanks, Tom. So as Tom mentioned, and this is very important, we're not gonna do a lot of detailed numbers crunching. I can relieve you of that as you're trying to get into the afternoon. But the tools that are listed here that are available to you include like a seven worksheet workbook of very pragmatic ways for you to model out what you're doing. And I'm gonna be showing you some screenshots of those. So just keep that in mind. The tool is there. We're gonna give you examples and then you can go back to those and use them as you're trying to do your own work. Next slide. So this is kind of my mantra that I keep coming back to. In a way, we've gone through a very important discussion earlier today, but it really has illustrated the complexity of the external environment. And the good news is you don't have to work with all the payers and you don't have to know everything about what everybody else is doing, but you are gonna have to find certain partners whether it's the health system, a hospice, a payer, whatever. There are some be some partners for whom you have to do the work we've been discussing. I'm gonna focus on knowing yourself because if you actually are not clear about what you're trying to do and you can't define the services that you want to be able to offer that will be helpful to patient care, and you don't actually know what drives your cost, it's gonna be very hard to get paid right. Now that seems obvious, but I want you to dwell on that, that you really will not be able to figure out whether you're doing okay or whether you can accept a contract or what types of patients you can work with and say yes to if you don't actually know what it costs you to do it and how different models affect you. So this is all about very practical stuff on that. Next slide. So this is, once again, I'm a finance person. You know, I have an MBA. I've worked on the healthcare business side for 30 years, but I'm telling you it's more important to answer these questions than it is to perfectly sharpen a pencil and calculate everything correctly, right? It's the big stuff that you need to know what you're doing. Why are you doing it? Who brought you to the dance? Who are you trying to help, both from a organizational standpoint and from a patient care standpoint? So if you're coming from a health system into expansion into home care, you're going to weigh certain measures more, like reducing readmissions for case-based or risk-bearing patients. If you're coming from a hospice, you may weigh certain outcomes differently. You want to think about that and know it, independent of a contract or a price, because it'll help you not be reactive. What you don't want to do, what is bad business practice, is to try to make everybody happy or to try to say yes to too many players and have to do things five different ways, right? You'd like to have a fairly consistent way of training your staff, of managing patient flow, of scheduling people, and you want to feel good about the quality and consistency of your practice. In order to do that, you have to know why you're doing it, and that will help protect you from reactive negotiation. You want to be proactive and have options. You know, we talk about pilots a lot. We also want to talk about options. You have options for how to do what you're going to do, and you want to keep thinking about those while you're probing and listening, not react, so it's a yes or no, right? You don't want to get into a yes or no, you know, we'll take the contract or we won't take the contract. You're going to be in a lot of, you'll go from piecemeal fee-for-service to piecemeal everything else, and that's not going to work well, okay? And so then you want to think about knowing your customers, and I'm using the customer word deliberately, because to me, the customers, it could be referring clinicians, it could be a payer, it could be the vulnerable underserved patients that you're trying to help, that you see falling between the cracks, but think about why are you doing this and who are the key constituents you're trying to navigate towards a sustainable solution, and it's usually going to be more than one. It may be a combination of a partner or payer, practice or provider group, and some target patient populations, but really think about that. And then this is something people do, often, this is probably the single biggest mistake I see people make, is that they try to do things very incrementally, and what I want you to think about is designing at scale. That doesn't mean you might not get started at a smaller level, incrementally, but if you actually don't know what success looks like, if you haven't spent the time to think, huh, how will I know when I get there? Like if I go year three, because to me when I think five years or seven years, it's too far out, too many things change, I can't think that way. So I think, okay, in three years, if I've been successful and I've cobbled together a portfolio of services and a portfolio of staff, and we're doing our work well, what do we want to have? Is that scale 300 patients served a year or 3,000? Is that the two counties near where my organization is strongest? Or is that going to be a third of the state or four states? I mean, that matters, right? It matters who your partners need to be. It matters what your delivery system's going to need to be. And it matters what systems you need to put in place. When you think of the mundane things like billing and documentation, knowing where you're going is very important. If you are an incremental program, that is trying to simply serve a small catchment of patients coming out of one hospital, it's going to look very different than if you're trying to be a multi-line of service business that can provide good care and continuity and be the partner of choice to people in your market. So I will always encourage you to think about what does it look like at some level of stability? That also helps you think about what your stable mature cost is versus your startup cost, which is a very important concept. Then you can evaluate, is that feasible? Do your key partners buy into that, whether that's your own organization and leadership in your organization? You want to get the buy into that. Then you can ramp up in a very planned way that doesn't overextend you in year one and year two, right? But try and plan to scale. I find people skip that step. Next slide. All right, so this was hit a little bit in the earlier session, so I'm not going to spend a lot of time on it, but we're constantly talking about those conversations with your partners, right? It's not about trying to sell them something or convince them of something, it's what's the problem that keeps them up? Who do you need to work with? So as a consultant, I interview a lot of referring clinicians, for example, and they will say, I need reliability. Like, if you're going to take on helping me with patients, that I need you to know what your response time is, to have you close the loop, to not have that service not covered because somebody is on vacation. I need reliability. And to them, reliability is reliability. To you, sometimes it's 85% of the time, we did that within 24 hours, but 15% of the time, we didn't. They'll remember the 15%, okay? So I really want to understand what matters to them. Sometimes I ask hospitalists what matters, and they'll say, well, I want 24 seven, and I want, you know, all that. And I go, well, what's more important for you? That someone can get to the patient on the weekend, or that they can do it at 9 p.m.? And they go, oh, well, actually we're, you know, in the hospital, we're covering overnight, we're actually there. It's more important that they can cover on the weekend. That is a very important differentiation when you can't do everything for everybody, right? So you really want to use a needs assessment process to understand what's important. If it's a crisis patient and you're doing pain and symptom management, timeliness may be very important. If it's co-management with some patient populations that are very high risk, but without imminent disaster, it may be okay to schedule two weeks out, right? So you want to think about who you're working with, why you're doing it, and get their engagement of what's important. Then you can plan. You can think about the trade-offs in the options for how you staff and how you grow and what you do. And then you're set up to do these pilots and implement incrementally and be flexible because nothing will go according to your plan, right? It will not be perfect. But if you don't have a vision of where you're going and you haven't understood why those assumptions are important, you will make less good trade-offs in the incremental decisions and in your relationships and in your contracts. Next slide. So this is really, this is the math and it isn't that complicated. So usually folks are like, oh, this is going to be so complicated. It's really not. You're trying to focus on what are the value equations you're trying to, you know, what have you promised and what will it cost you to do it? And you want to be realistic about capacity and friction, right? Like the example I think Laura gave of, you know, the no-show, like you go, you can go all the way to somebody's house, but then they ended up having to go in for an urgent appointment and they're not there. Or their family member who needs to be there when you're there is not there. That is a very expensive miss. So what are the things you're going to build in that allow you to have reliability about your assumptions? Who are you going to serve? How frequently, frequency, duration, team composition, and where you're going to touch stuff, which is not going to be just one answer. Like even two years ago, it was more, we need to go to the home. Now it's, well, how many times might we need to be physically there versus if we've already assessed the patient and they know us, can we do some of this telephonically? Because if we can do some of it telephonically and they're happy and we can get what we need and we can bill for it, that could make a big difference in what your model says your break-even is, right? So you want to think about that. A program that says, oh, we're just going to do goals of care is going to have a very different model than a program that says we're going to help a certain specialist co-manage patients who are extremely sick and at home, right? So you're going to need to think that through but these are assumptions about your operations that drive your business model that drives your budget. So the spreadsheets are built from these assumptions. Next slide. All right, so I'm just give you a quick example and we're going to go look at a couple of spreadsheets which we're not going to go into in detail, but this will help you get an angle on it. So here's an example. And these are extreme and y'all are doing, people on the phone, y'all are already doing a lot of interesting stuff, right? But just for sake of argument, if what I'm really offering is why, if this is a patient who is not actively dying now, right? They're in the hospital, they have serious conditions, they don't have good family dynamics and goals of care in place. And it's really important to get these things done because it's going to be a complicated next three months, right? It's not going to be a simple, straightforward next three months. If we had a good home-based program where we could really ensure the inpatient team, whoever that is, the hospitalist, the inpatient palliative care team, the oncologist, I don't know, but if we could say, hey, we can actually get them a video visit or a home visit within X amount of time and we'll do this and we'll have the family have time to be there, it'll be a less pressured situation. You can go on and discharge the patient. We're not having to wait for the sister or the daughter to get here. If you can do that and we can get that done within two weeks and in the medical record for you, then that might increase the odds that they can discharge the patient and save a day or two in the hospital, which is good for the hospital, good for the family, right? That could be a very good service offer, but that is a limited offer with a certain set of expectations. You're not saying you're gonna follow them forever, right? Another type of offer might be that a patient that's going to be discharged really has a lot of complicated medical stuff going on right now and they're fragile and they're highly likely to have a readmission if they're not managed really well. So you're gonna instead say, well, what we're doing is after they get discharged, we're going to get someone, a provider, someone who can write medical orders. We're gonna get somebody there who can do pain and symptom management, et cetera. And maybe we need them to have, maybe we need to do a visit within 24 hours or 48 hours and we need to have a certain type of team. But then once we've stabilized and ensured they got their medications correctly and things are going okay, we might follow them for several months. Okay, how will you communicate back with what other providers? What are the expectations? What are you having to document? Blah, blah, blah. Those are both valid. They're very different in the assumptions you go into a business model. And in reality, you may do some of both, meaning many larger programs are gonna do some of both of these things and five others. But if you think of them as separate service offers and how they affect your model, it's gonna help you. So let's go to the next slide. All right, so these are the assumptions. What's your service offer and why? And I realize you're gonna have multiple service offers and you're gonna have to morph it, right? This is not gonna be a one-to-one game. But the more you think about each one separately and play it out, you'll start to see synergies because how can, what will support a full team? Are you gonna go for geographic breadth or depth within a market, right? You're gonna start to see these things as you play it out. Which patients and how many are you planning to serve? You won't know the right answer, but you need to put some stakes in the ground or you can't model it out. And then why are you staffing a certain way and what are the trade-offs, right? I mean, whether you're doing fee-for-service billing or whether you're doing something else will influence your mix of providers and what you do telephonically and how you do the work. All right, next slide. All right, so this is a screenshot of one of the worksheets, okay? And so I just want you to see, we have these things in here where you can go in there and put in the staff you want and what your pay rates are, et cetera. And it's gonna give you, based on FTEs that you put in, you'll be able to use this to build out a budget model, which is in another spreadsheet. Next slide. This one shows you that you'll be, this is fairly important. I'm a real nudge on this one, that people use generalities and get themselves in trouble. So they'll go, oh yeah, we have one FTE and they can do all of this work. And I'm like, well, who covers for them when they're on vacation? Like, I'm not a big fan of one, two or three FTEs. I'm a fan of having enough scale that you have cross coverage. And if somebody gets sick, you have coverage and you don't reschedule appointments and you don't have a long wait time, right? And nobody works all the time. So, and every organization has different rules. So I just want you to think about it. This is in that worksheet. You have to think about what your assumptions are. Some places clinicians work four days a week. Some places they make certain assumptions about patient care hours and other time. You have to have these conversations and you have to make these assumptions before you build a staffing model. And this affects it. So people go, oh, we have 52 weeks of coverage. No, you do not. And a simple, simple change, like how many weeks are available, but the difference between 44 and 46 is weeks a year is a difference of, you know, 150 patient care hours. That's going to make a difference, right? So you want to think about that stuff and how you monitor it or you can't do a budget. Next slide. So I think a lot about staffing models since I started out working in a capitated environment. And I always, and I usually work in the areas of things where we're not getting paid tons of money for our build work. And so I think, you know, first of all, if I lose money on every patient I see, then seeing more patients does not solve the problem. And having the most expensive provider see the patients does not solve the problem. So like in geriatrics work, often we're, what can we do with the social worker or with a clinical assistant who can make phone calls and check and follow up and get community resources and do things that are highly important to care, but may not be billable, right? We want to think about those things because depending on your service offer and your funding source, you may be able to use non-billable team members in ways that are both very appropriate to what their skillsets are, helpful to the families and patients, and actually more cost-effective. I think Alison was referring to that earlier. So you want to look for that sweet spot because I am more interested as a business person who wants you to do good. I am more interested in how to optimize access and patients served and to then focus the work that billable providers can bill for with them. But I don't need to build a model that replicates the fee-for-service world when I'm not trying to replicate a widget environment. All right? So I want to think creatively about my staffing model. Next slide. So this is another screenshot from the workbook that you can get online. And the columns that left off the titles because they're on a, this is a screenshot of a more complicated page, but the first two columns are two examples of year one. You know, just so you can see what happens when you change one variable. So you look at the one, the first column on the left, it starts with the average length of stay in the program in months of three months, right? And you look down there and you can see, and you can start to make changes and model it. The last two columns are intended for your use to put things in the green. And the first one would be like your startup year. And then the last column would be like year two or maturity, however you want to do it. But allows you to think about the fact that once you've been going a while, you're going to, even though you may see patients on average for say a duration of three months or four months, there'll be some patients you're not going to be seeing every month because you've already done new patient visits on them. So some of your statistics are going to change. The frequency of telehealth visits might change because you know more of your patients, right? There's more continuity. So it allows you to start modeling some efficiencies that might come when you get a little more mature, but you are able to go in and change some of these numbers, which will then recalculate and then go towards your overall budget. And just allow you to model things and think about sensitivity. What matters? How much does it matter if we assume that we follow them three months or four months? That's what the two right columns are. The difference if we follow them for three months or for four months. Now, obviously some patients are going to follow up for three weeks and some are going to follow up for six months. But the question is on average, what are you following and why? And how much staffing will you need given those assumptions? All right, next slide. And this is because I'm old fashioned. And so I date back to things like interest rate tables. And I like people to see things where they can just think about simple math and how it relates. So I am not saying you should only see patients once. I think you should see patients the appropriate amount of time based on what their conditions are and what you've offered to do. And I have a real visceral reaction when people have their staff get in the habit because maybe you're measuring their productivity and not anything else. They get in the habit of scheduling a follow-up every week or every month because it's a lot easier to do the follow-up on a patient you already know. And you fill your schedule and then you're busy and you don't have any gaps. And so you just start following patients. And all of a sudden, you're like a primary care at home model that's seen a patient 12 times a year, right? And you didn't mean to be there, but you end up there because your schedule is full doing good work that's appreciated by those families, right? So it makes a big difference how many times you visit these patients every year. And so I just want you to sort of see that down the left side is capacity, all right? So down the left side is, back to 52 weeks or 45 weeks, what your capacity per provider is. So the top number is 1,575. That's assuming that you're in the gray, that you're going to have a lot, as a full-time clinician working a lot of the year. And the bottom number is I've got an academic clinician who doesn't have very much clinical time and really they're not going to be here because they're doing three other jobs or they work for the hospice or whatever. 573 would be very low. But given that gray on the left, then I want to think, okay, how many average visits per patient per year am I thinking? One is low, 12 is high, but let's say I'm thinking is it two or is it four, right? This tells me how many patients I can see a year. So if I'm going to see four visits per patient and work 1,050 hours a year, I only have a capacity for 263 patients a year. Do you see that? So you really want to think about it because if you're working with payers and partners, they may value more a high intensity, shorter duration service that allows you to see more patients in a year with whatever your team is. And knowing this will help you in your realistic staffing budget. Next slide. This we're not going to spend time on. There is a worksheet, but I just want you to understand that depends on the organization that you're working for and what the rules are. A lot of times you're not going to be charged a lot of non-personnel expenses. They're looking at what your direct costs and your staffing is going to be, but you want to think about it, particularly if you're coming from a community organization, you really want to think about, are you going to need to go buy new software because you've got to do a certain, you've got to be able to do part B billing. What are the things you're going to need to do to equip your people, all right? So you really, you want to think about it, have discussions that have placeholders and there's a worksheet on that. The thing I would maybe nudge hard on having watched trial and error by places is don't, that's why you got to plan for scale. Don't short on the systems you need because when people send a couple of FTEs out there and they don't give them decent systems for billing and scheduling and documentation and connectivity to EHRs, they end up spending a lot more money and having lower capacity because the team spends half their time doing that stuff. So really think about investing in the systems you need that fit the scale of the planned mature size of what you're doing. Next slide. So we're hitting the end of this and we're going to have some discussion and I see there's some questions coming in. There are several key financial stats. So I'm much more interested in thinking about how many total patients I served in a year than how many visits I did in a year, for example. Those will drive what my cost per patient served is. I want to think about my cost or contribution margin, net of billing or contracted revenue, meaning where's my breakeven. I want to think about what my cost per visit is so that I know, and it doesn't mean I don't do a visit if I'm losing money on it, but it means I know what it costs me to do it. I know what growth costs me. I know what it costs me to say yes. You really want to know your breakeven and contribution margin, even if you choose to do this and continue it and subsidize it from other sources, you want to know. And you want to think about if you're dependent, appropriately dependent, not dependent on contracted or employed staff and how you can flexibly grow fast because you might sign a new contract and need to double in size and whatever value measures your stakeholders have set. So I believe that brings us to the last slide. Is that right? Yeah, Lynn. And so I think we do have a good, a great question that came in from Tina talking about this, the fear of a sticker shock, I guess, in a per member per month that you might propose to a partner and it being too high relative to what you've built in your cost structure, using your cost structure to figure out your PMPM. But just wondering what your perspective is on, how do you position that to a payer partner? Well, so one strategy, this is like know yourself first and then be ready for that conversation is if you were to go, you can build your own version. If you go into these worksheets and you play around with them, you can start looking at the sensitivity to certain assumptions. So if you've got a high PMPM, it's probably because you have a high number of visits or a high duration or a high intensity of provider, right? If you're gonna send, which doesn't mean any of these are wrong. If you're gonna send two providers out like a SWAT team and they're gonna be able to have 24 hour response time and you're going to follow up by phone every three days and then you're going to have a visit every two weeks and you're gonna follow them for four months, that's gonna have a pretty high price tag, right? But it's gonna be compared, these presumably are prioritized for patients who are at very high risk of other adverse outcomes, either hospitalization or nursing home or death, right? So you want to be able to tie your story to this type of service for this type of patient costs something like this. And you say, now we have two or three intermediate options. We can focus on this population in this way, right? But today you can't, nothing's free. So if they want you to solve all their problems and not have calls going to other people and not go to the hospital, it's gonna be expensive. But you have to play with that and figure out what you can afford to deliver that is appropriate within certain price points. I mean, I can remember back, this is not today, but back when Medicaid would say, oh, we'll pay an extra PMPM for care management, but the PMPM was so trivial that people wouldn't sign up to participate because it was like, no, then I've taken all this extra responsibility and I'm not getting paid anything for it. So I don't think you should be defensive, but you should know what the drivers are and what the story is around what you're offering and be listening about what they wanted to buy versus what you're offering. And you may want to say, that's great. That's great, good luck finding it. That's not what we do. That is okay. But you've got to know your own business or you can't have that come up. So I see, I'm looking at Tom, you need to help me here because I'm- Yeah, no, I just, I want to acknowledge too, somebody has asked about some rates and things like that, which is we just want to make sure that we work within appropriate competitive constraints in our industry here. So publicly available information. There's actually been some really good reference points that are publicly available out there. I think certainly the models that Medicare was coming out is one place that people have seen. So I think the questions and the analysis that you talked about and what Alison was talking about too is how do you really figure out what is your, the first step you want is what are your true costs? And have you done the right analysis to know what your costs are? And then to the point of where the reference points are, where payers might be, is really understanding what are the differences and variations of what your model is versus what others might have. And again, part of the challenges we're all dealing with in the country right now is the range is wide. If you're dealing with a highly complex, high psychosocial need of population, and maybe Rebecca, you can share a perspective because I know that's a lot of where you are. It might be in a different price point than if you've got a highly commercial younger population or something. There's a lot of variation that can happen on the mix that you have. And maybe Rebecca, you could share just a couple of nuances of what you've learned. Hi, yeah, this has been so great, by the way. Really love the framing of this, Lynn, and how concrete you're being about building your payment model or your pricing model. I would say that we followed a pretty similar practice in terms of trying to figure out how much our care model costs. And we've really looked at it from a multiple angles, how much does it cost to provide care, home-based primary care, home-based palliative care to a patient in a given time period? So usually we look at it in a month or how much does it cost to do one visit to that patient? So both ways to kind of triangulate the data. But I think that, you know, there's a lot of different components. We literally price every single team member, and I hate to use that word like as though somebody needs a dollar sign on their forehead. That's not what I mean. But we have to look at every single component of our interdisciplinary team. We look at how often those members of the team generally visit patients. And so we will start looking at it, we scale it for 100 patients. And we can do this because we have in our primary care program, we have 1500 patients. And so we can actually look at a over a year's time, what are the average numbers of visits that our nurses, social workers, chaplains make primary care providers make per a patient panel, and we usually use 100 or 50. How many telephone calls are they making? You know, really, how much drive time do they have? What is their mobile technology cost? What kind of mileage are they getting reimbursed for? How much does our answering service cost? And we, we build all of that in. So we have a pricing model that has our indirects and our directs. And the directs are made up of all these separate components of our team model. And then we test. So we'll look and I'm looking at it right now. And you know, just as an example, I know about I know that it costs about $15 for one of our nurses to make a 15 minute call to a patient. So that's just in general. I also know that when we send a palliative care nurse out or a social worker, and they make a true visit to a patient, and that visit usually lasts anywhere from 45 minutes to, you know, an hour and a half, that it costs us at least $165 for that visit. And so I can then go and look for fee for service rates in the marketplace to see if I'm way over what what other payers, Medicare, Medicaid, say as a reasonable cost, and they may be underpricing or underpaying, but at least it gives me a general sense of am I just asking for the moon here when I go to do a contract negotiation? Or is it, you know, within reason? And then also, I agree with Tom looking at some of the capitation rates that are coming through on primary care first, and the direct contracting model has been really helpful for us. CAPC has some information out there. But I would really encourage all of you to do the exercise that Lynn is suggesting, because, and I actually want to redo ours based on a little of the nuance that she's providing, because I think it's, it's, it's one of the things that healthcare providers, most of us don't go to school to learn this, you know, I'm a nurse. I don't have an MBA. And I had to, I had to really switch my thinking around, you know, if I'm going to be able to sustain this program, and stay in the in the community serving these patients, I've got to have a sustainable business model. So yeah, and go ahead. Yeah. Well, you finish. Well, and Tom just asked specifically, I mean, we definitely do. We have looked at the, it's, it's more expensive for us to care for a dually eligible or Medicaid population in our home-based primary care model than it is for us to take care of, you know, a frail elderly Medicare recipient in general. I mean, there's always exceptions to that. But, you know, we're just providing more service, and we're having to do a lot more community referrals and coordination. So we know that that's more expensive, and we have a pretty good idea of how much more expensive it is. So first of all, it's wonderful that you have done that and know, and I just want to step back, as you alluded to this, knowing doesn't mean that all of your decisions are made based on, I mean, you don't say, well, do I have to get my costs down to what Medicaid is paying? It's not that you necessarily do that. But if you don't know what the drivers are, you can't even think about how to modify the model to accomplish what you want to accomplish or to discuss what the trade-offs are. Right? And so, and there are a couple of questions or comments in the, in the chat about some of the non-billable providers and other staff. I think that you should think about the staffing for intake and marketing, et cetera. Some of the best investments I ever see are for what I think of as wheel greasers triage people who can, can call out and say, you know, hey, you have an appointment scheduled for tomorrow at nine. Are you going to be there? Is that still a good time? You know? And so you don't have a no-show appointment where you go out and you can't see the patient, which I think Laura had mentioned earlier. And the idea that you might think, well, what are the trade-offs if we hire a kind of a community organ, a person who really knows the community resources, and we can refer internally to that person or to another agency we work with to help get people community resources instead of our noble providers trying to do it all themselves. How can we then focus on what we can do and get what the people, patients need, right? And there are some, there are some contracts you want to pass because they're actually going to create more requirements and work and hassle than the patients you're going to get. You don't really want to have 18 different contracts, all operating differently, right? So you know your business more, it will be easier to make good decisions. Who's trying to say something? I'm sorry. It's Alison. And I definitely couldn't agree with you more about walking away from something. I just wanted to make a suggestion. This happened in Minnesota where there was a payer that was trying to get this off the ground and the providers made that decision. This doesn't make sense. We're walking away. At least give feedback because who knows, your partner might change where they're standing based on your feedback. So I agree with you. Walk away from something that doesn't work, but let your partner know why you're walking away. Absolutely. You're not stomping your feet. You're absolutely right. And the thing is, you're really illustrating that you are serious about providing a high quality service and you understand the population you're serving. Therefore you build these things in. So therefore you don't look just like someone who's trying to sort of skim. But if you don't know, you really... And one last thing, I think we're about... Well, I guess we got a couple more minutes. But one thing that I also think, and I'm sure the folks who have run programs for a while have seen this, you have to really redo this internally, not to say that the most productive employee is the best employee, but to look at variation in results across team. Because you're sending people out to the home with different practice styles. And there is a wide variation in discipline, and I'll use the word productivity, in good use of time. There's some people who can have a very effective home visit in 45 minutes. And there's some people who spend two and a half hours. And there's a lot of friction in how time could get used. And so if you don't actually... If you're not a good steward of your own resources by understanding them and working with your group to help people improve the overall effectiveness. Like one person going to the home may be calling the community resource person and getting help, or calling the administrative support person and asking them to follow up. Another may be sitting in their car trying to do it all themselves before they leave the house, right? Those are important. So our awareness and the transparency with which we understand our data and ask our team to help us understand variation will be very important to getting to a sustainable scale, regardless of how people are paying you. Right. Yep. What are you saying, Tom? Other questions? Well, there was a question that came in around fee-for-service rates for non-billing providers and social work. And I think it was directed to Rebecca. Yeah. So we have actually terminated every single contract that does not pay us at least a case rate on top of fee-for-service. So it's just picking up on what Allison and also Lynn was saying. We've determined that our model, in order to preserve the integrity of the quality of care that we're providing, our model needs to include, it needs to be team-based. And if we can't cover the services for all of our interdisciplinary team members, then we just lose too much money. And so one of the first things that I did when I came over to lead the organization is look at all of the contracts. And we ended up terminating probably two or three of them with Medicare Advantage plans that just weren't willing to budge on providing a case, what I call a case rate or sort of a PMPM on top of a fee-for-service model. They vary. I've not been able to get everyone to agree on the exact same PMPM. But the reason we do that is for what you're saying. We can't typically, I mean, we can use CCM minute billing. So we do a lot of chronic care management billing to try and cover the costs of the care coordination that our nurses, social workers, and others are doing. But because we do a lot of field-based care with those social workers and nurses, the CCM fees don't cover the cost of those team members. So we do believe for our model that that's what we need. And we've made choices about contracting with payers. Rebecca, one really nice thing about that is it allows your team to practice a fairly consistent type of care and not feel the moral distress of trying to differentiate the care across the payer type. Because the more you can have that, the more likely you are to have other positives come with it. And I want to just add a question that I know a topic that often comes up. And I know, Leanna, you've got some perspective too about trying to figure out this dimension of what's an appropriate caseload for a provider. And I was wondering, Leanna, if you wouldn't mind sharing some of the logic you guys have built around what makes sense. And do you do it by team or individual, et cetera? Sure. Well, thanks. Well, Lynn, numerous times throughout your conversation, I found myself wanting to hit the little clap button. You get on so many points that bumps and bruises. So we budget by provider. However, the team is a multidisciplinary team that supports multiple providers. So it's a little bit different. We've been at this about seven years. I would say these tools are fantastic. As you already alluded to, you need to continue to assess because the landscape continues to change. For example, year over year, we'd had about 25% growth. When COVID hit, we had 25% growth in that first quarter. We work in a healthcare system that historically operates an RVU for measurement of productivity. We started down that path with the home-based program. That is not a great idea. We learned that and have some bumps and bruises from that. Patient panel, again, depends on variability. Variability meaning we kind of land about 120 patients. But then there needs to be some standardization of workflow that you've referenced because you have differentiation of styles and providers work very differently. And if you're using some ancillary and non-billable services, coming up with that standardization as well. But we continue to evolve and have that discussion frequently, probably quarterly, both internally within our team as to patient panel and sometimes as the acuity changes, as our growth continues, or for example, somebody's out unexpectedly, as you referenced, for extended period, then we need to make adjustments. Great. And I want to just a math piece that you alluded to that I want to emphasize because it was buried in some of those screenshots of the spreadsheets and that, what I call the two by two grid that I referenced interest rates. It's so important. My average panel size might be 120, 120 patients. But if I follow those patients on average three months on average, then I can serve 480 patients in a year, right? Four quarters in a year. If my panel size is 120 and I see them once a month, twice a month for a year, then I can only serve 120 patients a year. And so, you know, and you've got to think who, for sake of what are we doing this? Who is our partner? What's appropriate for the patient? Because with some partners following the right 120 patients, I am thinking of, I have one time interviewed a man who ran a pediatric palliative care, primary care medical home, which was a phenomenal thing to see carried out. And he had a small panel size of very intense patients that he followed for often several years, right? That is a different model. I mean, that's a very intense population that's going to live a good long time. And that needs that type of panel size. On the other hand, if you can think about your service offer and how to make it easy, think of rewards and not making RVUs, how do you make it easier for people to say, we've done what we, you know, we've done our good work and now the patient can be followed by their specialist or, and now the home care folks are doing a fine job, right? We don't want to build dependency. And the more our staff, and it's just like, if you've ever worked in the inpatient side and you've seen the inpatient hospice unit, those folks thinking that they can't discharge the home to the freestanding hospice, because they don't know those folks are like, no, we're taking great care of these people. And they won't discharge them even to their own partners, because I think nobody can take as good a care of them as they do. When you build that culture, you're going to end up with a high cost model and a low capacity, which is going to make it hard to operate. So you really want to start from the beginning with a staff culture that is consistent with the type of service you're trying to provide. So I want to just acknowledge time for a moment. I think another element for today's conversation was also helping you think through who you might need on your team. And I think Rebecca and Leanna, you both have in different ways brought this forward to that. You need to find folks on your team to help you do some of these calculations and having a good administrator or business person. But the beauty of it is, is you've got to match the clinical perspective and patient with the business and the numbers. And hopefully today, everyone got a good framework, the tools that are out there are available for everyone. Lynn, thank you so much. Always amazing approach to it all. We are going to go on a break. We have a 30 minute break. I want to again, encourage you not to get off the zoom. Please just put it on mute and close your video down. We will start back up again at 30 minutes after the hour. And for those in Hawaii, I hope you have a nice breakfast and for the rest of us, grab a bite to eat and get some nutrients. And thank you all. So this is Karlyn, obviously I kind of know where you're at already, but the one thing that I keep coming back to through this webinar is, are we really able to identify our patients at a system level electronically? Karlyn, this is Allison, I'm not sure I was supposed to hear that. If you're a member of CAFSI, we have some great tools that can help you do that. Yeah, who was that? Oh, that was Allison Silvers. We have a patient identification and assessment toolkit and there's just some, it's, you can play around with how you weight certain data fields, but there's certain diagnoses that are great to use as, as triggers and then the other pieces of need are just always captured in the EHR. Hello folks, it's 27 after. We'll get started in about three minutes. So just about one minute, we will start up again as you're coming into this. I would love to have folks share in the chat, you know, what's one nugget or a couple nuggets you've picked up? Either what you've learned that's validating your path or maybe something that's just causing you to reflect on your program a little bit differently and thinking about your your design or your approach. So I'd love to have folks take a minute and just put anything that comes to mind in the chat. All right, I just want to confirm we've got our voices of experience back with us. Allison's back, wonderful. Ray, thank you. Yes, know your team very well. Excellent. And again, just want to hear from folks. Anything, any nuggets you've picked up on, the insights that would help. Diversifying program model types, excellent. Cost analysis business plan, yes, wonderful. Great. Keep posting there, folks. It's really good to kind of see kind of what's resonating and also where we could redirect ourselves. Key customer PCPs, wonderful. Okay, so we are in this next portion, we've got two sections in this. Both of them are taking the operational perspective now. How do you operate an effective and efficient program in a value-based world? So a lot of the discussion we've said so far along the way is going to start to hit home here about how do you apply and take your plan and actually operationalize it. The first portion, this first 50 minutes or so, is going to be focused in primarily on program staffing and design, and then I'll lead that. And then Allison will be doing a portion around stratification and really thinking about engaging patients and how to do that effectively in these models. So this is when we start moving into how you run the puppies. We do have a couple important tools, again, some staffing models, as well as some proactive identification guidance as well, and I'll put that in relevant terms in a minute. So with that, let's jump into the first slide. I think we've had a pretty consistent theme that we want to just keep reinforcing that when you're working on a program and you're working on a contract with someone and you're delivering a service, that mindset of really delivering a consistent access and quality is fundamental. So how do you make sure that the team you've created and the model you've designed can be and is reliable? So waiting lists, as an example, that's taking a long time. I've worked with programs where they start out and they've got a couple of nurse practitioners out covering two or three counties, and they're running solo. They're hard to keep up. There's not an infrastructure around them. They're not very reliable, and it's hard, and they're trying to figure out why they're not getting traction. It's because you're having a hard time having that whole mechanism for follow-up that you need, and even a full team. So there's a good example. Not being confusing is another big piece about your design and your team design. Thinking about, you know, one element is certainly eligibility criteria. Who is appropriate to refer into your program? If you're working with a referral partner or if you're working with a paying partner, whatever it is, and you say, well, those but not those, but these yes, these are no, and it gets confusing. You're trying to create some level of consistency. It's also really important for your team so that your team is not confused either about who's coming in and who's getting assessed and where they're going within your program. And then that consistent results, again, timeliness, but regular processes that you do, having some consistency of triaging, all those processes are very important. So I would love to have folks give any examples that you might have of what you've run into when you've had a lack of access or inconsistent practice, and how did that create a problem? And again, with the idea of posting some of these ideas into the chat, we'd love to start to see what's popping up around that. But we just wanted to really hammer home that first message that you are delivering a product and a service. And how do you design it in a way that you're not overcommitting, but you're committing the right level of service to be reliable? Next slide. Next slide. Oh, I'm sorry. Can I just add a tiny bit of color commentary? Oh, Allison, are you trying to say something? Oh, yeah. You can't hear me? I just wanted to add a bit of color commentary. Still can't hear you. Do you want to post it in the chat? I can hear her. I can hear her. I can hear her, too. We can hear her. Okay. Keep going, Allison. I guess I can't hear you. Okay. Sorry about that. Anyway, just back to the point of the program eligibility criteria. So it's also about having, it's called never saying no. So even though your program might not be equipped to serve, let's say, a substance abusing serving population, you should know out in the community who can serve those. So you can say, oh, yes, thank you for the referral. I'm going to hook Mr. Jones up with ABC organization. So having those ready relationships in hand will, it makes you a better partner to your referrers and your payers if you don't hand them back problems, but you figure out where the patient can go. I'm not going to hear you now, Allison. I'm not sure what happened. Woo. And I think another big part of that is, is that good service, you know, ripples through the community, too. And, you know, sometimes your best advocate, your best seller is someone else saying this service is really important and it's very reliable and I need it for my patients. And so I want to acknowledge that. If we go to the next slide. Again, how your payment model drives your staffing and design. We've talked pretty extensively about this so far. We'll go into some more detail, but, you know, conceptually in that billing fee for service world, you're really managing volume. As you move into that fixed payment or a case rate, you're really moving to managing capacity and thinking about best top use of different resources and everyone operating at their, at the top of their license. So let's go on to the next slide here. What we wanted to hit on was three or four points of context around design to be thinking about. So first, team structures. So how do you adjust your team structure? For example, you might have in the past in a fee-for-service world been having that position of that APP out doing a lot of these visits. In your value-based world, when you're getting a fixed payment per month, you're able to flex what makes sense. And so thinking maybe about best use of that APP or position might be that they do more time at the upfront doing the intake, really assessing what's needed, and then shifting over time to having the RN or the social work doing different elements of that work. I'll give you a pragmatic example. Sometimes it's helpful, but working with a group where you're thinking about pods, and you might have a pod that's made up of three RNs, and each of those RNs are basically the quarterbacks for a panel of patients. Let's say it's 60 patients. And then in that pod, you've got an APP or a physician, and you've got a social worker. And that group and that team might cover a particular region. It all of a sudden gives you that flexibility to start operating in a way where you're using the physician to their highest degree or the APP, and then adjusting targeted strategic use of the social worker with that RN really playing that quarterback role. So the design of your team in that model can be just an example. There are some programs that are adding paraprofessionals to extend the services. There's even some that are partnering with EMS or EMT services to do some of the 24-7 coverage and weekends and, you know, catching people in their homes and helping them stay at home. And then just a big message around that, staff, we've talked about some of that today, is these tradeoff issues. You know, you're not trying to go to some far extreme one way or the other as you're making those adjustments. I mean, there's still an important, you know, relationship you need to have with the treating clinician. Well, who's the best person to have that conversation and that relationship with the treating clinician? But the tradeoff is that you still want to have maybe our end of the social work doing a little bit more of the heavy lifting. So how do you adjust kind of the best use of that? You might be thinking about program certifications a little bit differently, and then thinking about quality and patient relationships. So just tradeoffs and how you design your teams is what you want to make sure you put into your forefront. Next slide. A big part of this, and we've talked about this a couple times, really being thoughtful and careful about the right patients that are most appropriate for your service. And sometimes it is easy, particularly at the beginning, to say we will take anybody. And you really want to be thoughtful about who it is that you're seeing and how you're going to grow your program to meet those highest need patients that your team can support. Thinking about triggers or some sort of proactive identification, thinking about the combination of diagnosis, utilization patterns, frailty markers, and Allison is going to go into a lot more detail in the next section on that. But again, how do you think about the funnel in of patients that are coming into your practice? And as you think about that design and you think about that team, you want to make sure that they're following a consistent practice there. And thinking about data that might be available for you, too, if you have a good partnership with a health plan. They've got a lot of hierarchical condition categories. There might be data that you have around LACE, your health system has around LACE. So using different data sources to think about the most appropriate patients. And then also, and again, we talked about this earlier, is that discharge element that, you know, to Lynn's point about the math, is that if you're following and caring patients for a very long time, that precludes you from being able to see the next group of new patients. And so thinking about those that might be appropriately to be stabilized and can be moved back to a primary care practice and appropriately transitioned back, or maybe they're appropriate for hospice. So really thinking, again, about the most appropriate patients that could use your service is a big part of it. Go on to the next slide. So I think in COVID, we've all seen this change overnight about the use of virtual encounters, et cetera. But again, thinking about the extended use of your team, if you're been working through a model that's primarily fee-for-service, you've now moved into a model where you're trying to make best use of everybody, thinking about that best use of that virtual encounter, it could be a phone call. So you might want to do an in-person visit once a month to check in, but you might do more strategic reach-outs and calls to patients through a phone call that the RN might make, et cetera. So best use of that telehealth and telemedicine. There is a lot of debate out there, certainly, as we all know, about when's the best use for it, and some stronger recommendations as we talk to home-based teams is certainly starting with that face-to-face, in-person makes complete sense. You get to know that patient. They get comfortable with you. I think there's another piece that we don't always talk about that we sometimes hear and run into, which is there's a lot of different people that could be coming to these people's homes. And, you know, not assuming that they want you in your home, in their home, I think is an important lesson that we've heard. And if you go to the next slide, when we think about making sure that we're not duplicating services. So if you think about best use of your team, there's two arms of it. One is you don't have to deliver everything. If you can find good arms and legs that are already out in the homes and you can build a relationship with them, you could use information from them to help prioritize what your team is working on. Certainly, you can also be an advocate for services that they might be qualified for. So there's elements of thinking about the scope of what you're doing and making sure that you're not taking too much on and duplicating. There's also a lot of services and case managers and others that are growing out there. Certainly health plans have done it. And I've heard stories where people said, you know, they went in on Tuesday and then a health plan case manager came in, had just been there on Monday. And the patient's confused, and they're not sure what happened. And that case manager said this. And so there's a lot of that coordination that you want to be aware of. And again, not just respecting the fact that too many people could also be in the mix and you want to make sure you're not duplicating that. And then we've talked a little bit earlier about chaplaincy and how to integrate that. And certainly thinking about community-based and faith-based organizations that can provide some level of support, friendly visitor support, caregiver respite, and other services. So minimizing that duplication. If we go to the next slide, again, emerging, growing evidence, using community health workers, you know, again, the eyes and ears of folks that might be out there that could help inform and help give some insight. I was on a call a couple days ago with a group that does a lot of virtual work. And they actually had a massage, they had funding for a massage therapist. And the massage therapist was going in. And when they were there, they were able to bring back insights to the team. And it was, I just listened to the team decide, okay, what did you hear? Okay, actually, let's send someone out in two weeks. We'll call them next week and schedule something for a visit. So they were able to get some views from folks that weren't just the clinical team. And I think community health workers are a big example that we wanted to highlight there. If we go to the next slide, you know, we certainly want to, I went through that fairly quickly. I want to kind of just pause for a minute before we jump into the breakout sessions. And just pause and, you know, Allison, there's a lot to unpack here. We've had a lot of discussion earlier. I wanted to hear your perspective or any insight before we jump into the small groups. Thank you, Tom. Yeah, I would just suggest, I think there was a comment in the Lynn section earlier that our program is really, really expensive and the payers are balking. So to take a look at what is driving the expense in your program and brainstorm on what are the opportunities where you can get the expense down. And again, we went through them. There's stuff in the chat. Community health workers, unfortunately, are a lower salary and really do play a pivotal role. And I'm not sure enough programs are using them to the fullest extent that they can, which would just save nurse or social work time for patients who might need something a little more skilled. And then the virtual, there's a raging debate. And I'm sure in the breakouts, we'll start talking about this. But when an encounter can be done virtually, it gains you about 20 to 30% of the encounter time overall is what we've been hearing. So it really can be an opportunity for efficiency and getting your costs, your price down, just some things to consider. Just hitting on those a little harder. Yeah, and I think Lynn mentioned this earlier too. And again, I've seen in some practices I've worked with, you know, first of all, that triage role and the criticality of it to really help funnel information back and forth. And I know some of our voices have experienced, you know, you've almost got to continue with services. And it might be, you know, you get the referral in for something and you say, really, the home health team might be better for that. So there's a lot of that that I think is an important element of your program design. The other one is these logistical issues. I know really investing in a good scheduling system, it sounds very boring. But you've got people driving all over the place, making phone calls. Where are they? They're trying to do it between. They're doing it, you know, eating their lunch while they're standing in a parking lot. I mean, this home-based space has a lot of infrastructure that needs to be built. And figuring out the right efficient mechanism to design the program in a way that makes sure that scheduling is efficient, that documentation is done, you know, once and simply, what is the best use of the team's time that's out and the team's time that's back at the office or back at the home base. I think those are really important design elements, too, that sometimes tend to get overlooked and people just jump out and start running. Any other comments, Allison? And then we'll. Oh, I was just responding to Janet in the chat about patients being able to use technology and making sure virtual visits. I've heard really great things about using CHWs, sometimes even just through the telephone to set the patient up appropriately, so a little bit of investment up front. Again, the advice that CAHPSI hears a lot is the first home visit or the first visit should be in person. And maybe that's the time that you set up the iPad and you get things working. I know it's not perfect, but. Great. All right. So we are going to go back into our breakout groups. You should be staying in the group that you're with. There were a couple movements around just because some folks wanted to be with their organization, so we matched some of those folks up. So bear with us, but we're going to go 10 minutes in this breakout group. The key discussion we're having is really sharing with each other what ideas do you have to improve that efficiency side of your model without sacrificing the quality? What are the dilemmas and tensions of transition from the fee-for-service to the value-based in that more operational space? And honestly, what's worked or not worked? And certainly want everyone to share with each other in the room. So with that, I'll turn it to Melissa and Sarah and break us into our rooms. And we'll be back in 10 minutes. Tanya, you should have received an invite to go into your group. Did you see that pop up on your screen? And here, I think you're muted here. I got out of it and then had to get back in and said to retry. Sure. Do you remember which group you were in? I am with Laura, I think. Let me find your name and let me go ahead and send you in there, okay? Okay, thanks. Thank you. Hi, Jen. This is Sarah from HCCI. I know you're getting into your breakout room. Do you remember which breakout you were in? Oh, good question. I do not. I'm sorry. Are you here with the team or just by yourself? I'm here alone. Okay, then I'm just going to put you into a group, okay? Okay, thank you. Thank you. Hi, Lori. I'm going to, this is Sarah from ATCI, I'm going to put you in your group in just a moment, okay? Lori, you should have received a message sending you into the group. Please feel free to join that group, okay? All those breakout rooms are always so fun. Like you're in and pop in, pop out, then get yanked someplace. But that's all right. It's keeping us all moving, right? We had some good insights in our group just talking about that transition and that trade-off. Just Tiffany's example she was talking about was the trade-off of how long do you follow what model might work best for you that you might wanna follow a patient all the way through into hospice or however far you might wanna follow them to have that continuity and that trade-off of efficiency and effectiveness, what makes most sense for that patient and for your team, a lot less handoffs, a lot easier communication. At the same time, it precludes your team from seeing the next new one. So how do you figure out those trade-offs is one thing we spent some time talking about, certainly the use of telehealth and telemedicine. So we wanna now spend some time with our voices of experience. And this is also open Q&A time for folks. But we do wanna move in and start to hear what our colleagues have done. So this has a lot to do again with staffing and program design. I'm gonna start with Russell for this one. Russell, you did some changes in your program flipping around paired visits versus individual versus virtual. Would love to just have you share your journey of what you guys did, what you learned and what you're doing now. Yeah, I think that when we started in this space, which was around 2014, our frame of reference was our inpatient teams and then a bit of hospice care where we were used to working very collectively as a team in person, so in dyads and groups of three. And I think there's great value in that. But when we started the home-based program and we had 50 patients or so, we could afford to do that. And it did work well. But when the volume increased exponentially, we had to really look at what it means to provide interdisciplinary or transdisciplinary care and how could we accomplish that without continually increasing our staffing. And we also found that the driving and meeting at homes with groups of disciplines wasn't always necessarily productive or the best use of the clinician's time. So we really do make, I would say, the clinicians see patients on their own and work very autonomously. And in most cases, unless there's a real reason not to do that, some of the work we piggyback on. So one person might start and another person finishes. But that was really key for us. And maybe at this point in program development seems like a no-brainer for most, but it certainly wasn't for us at this time. I would say my team was, from the outset, I think two unique elements of our program was even back in the early days, all of our initial visits are the assessments and the admission is completed by a physician or a nurse practitioner. So from the outset, they're very involved in the individualized care plan. Also, our social workers are the other discipline that will make visits in the home, but our nurse case managers from day one have always been virtual. And that again was a new model for me coming from a hospice and hospital background that's been quite successful for us. So the blended model has worked great for us. And my team has been over the course of time, very resistant, those who were not already doing virtual work, very resistant to that. But I think we've all had the experience that COVID has really changed that for us. And many or most, I would say, see the value in that. So at this point, we're doing a blended model on all disciplines. Russell, can I ask you a question? Because you mentioned, so you've got some staff that are all virtual. So, yeah, how do you handle the communication? Like, for example, do you have daily IDT meetings or is it weekly? How do you do that? I meant to include that, Tom, so thank you. We do a daily morning huddle and then a weekly IDT and then lots of communication in either the electronic health record or our platform for the virtual in-house meetings is through Microsoft Teams. So there's a lot of communication on the chat feature there as well. So the communication that would happen in those dyads is really pretty hardwired otherwise. Got it, and I was maybe thinking, Rebecca, as you're hearing what some of Russell's talking about, I'd love to hear your perspective on how you had done some work with RN, triage and elements like that, but how are you balancing some of that to what Russell mentioned as well as what you're doing for the team's efficiency? Yeah, I think I saw in the chat somebody talking about the difficulty with patients not either, just not being able to interact as well with the virtual platform, whatever virtual platform you're using. We've definitely seen that in our palliative care program as well as our primary care program. So we are trying to partner with adult foster home owners, facility owners, resident coordinators, sometimes our own staff to go out and set things up so that we can do more virtual care. Yeah, one of the learnings that I was gonna share, and this is sort of, you learn as much from your mistakes or failures as you do from your successes. So a number of years ago, maybe just, yeah, it was probably about two and a half years ago, we decided to do a mapping exercise, and this was really to gain efficiency in our program, to do a mapping exercise where we did some ride-alongs with our primary care providers to determine where they were maybe spending non-value-added time or at least not working at the top of their capability. And what we learned, one of the biggest reasons that they were not able to see as many patients in a day or that they were feeling, you know, having long hours or being late to appointments was because they always had to pull over while driving because they would get all these calls coming in from various members of the team, or, you know, they had to check their fax inbox because they were getting, you know, requests for orders from the facilities. And, you know, it was just so much back and forth, important clinical communication, but didn't necessarily require a PCP to answer. So we tried to reduce some of this by hiring an office-based triage nurse. And so we had sort of protocols with our receptionist, and when it was a symptom-related call, it would go directly to the triage nurse. And we assumed that that, you know, there would be some gain in efficiency for our providers and they wouldn't be spending as much time taking calls. The strategy did not have the intended results. And this is probably, I mean, as I look back on it, 2020 vision is probably a kind of a no-brainer, but we learned that the only way this triage nurse could actually save, you know, time was if that nurse was working off of very specific standing orders and protocols, which we had some of, but not a lot of. And so it just, it turned out that we sort of had the cart before the horse. And so we ended up, that nurse left, and we have not rehired because we're now in the process of really developing those clinical protocols and standing orders so that we can have, we can try it again in another way. So just one of many learnings. Yeah, the key is, yeah, I think the thing we're all finding, right, you gotta test it, figure it out, adjust it. Again, as volumes grow, as populations change, but there might be some fundamental stuff that you, you know, keep going back to that you wanna keep repeating. There's a lot of questions that came back on the question for Russell. One was the question about what was the frequency of your social workers visits? Russell, did you say that at one point? So they currently are, they are also involved in the initial assessment of the patient. They don't, again, they don't go out with the, with the provider, but most of them, they complete an initial assessment on most where they create their, an individual, an individualized care plan, and then are brought in by referral. Great. And the other one, and this would be a question, I think, for other voices as well, is your IDT meeting, there was a question about how frequently do you do it? And again, a little bit more detail. What does the structure of their meetings look like? And I think of it this way, as you know, is it, are you running a list every day? Is there one person that leads it, or is it each team shares it? How do you work through the IDT? So the morning huddle, they will review any new admissions from the previous day. And then there's a structure that, it's a little bit different. We have a wide service area. So some of my teams are meeting once weekly. Another team is meeting every other week, and it's a longer meeting. And there are some specific components to it. There's a six month review required on some patients that they do. There is a kind of a running of the list. They sort of decide who needs to go on that list. Then there is actually some time built into the meeting for some of our payers to call in, because when we're discussing some of those patients, and that again, it is, I find that kind of accountability varies and dictates by payer source. So that has worked well because we've built that into some existing time versus having to carve that out at another time. So is that like a case manager or someone from a health plan that's joining your IDT? That's fantastic. It's a great example of integrating operationally with your partners, not just financially. That's a beautiful example. And it's a good opportunity for them to really get a sense of the work. Yeah. I'll add to it with our IDT, we also incorporate education. We do it every other week. And because with palliative care, we have wonderful nurse practitioners, some of whom have never done palliative care before, and some of whom have. And so we do a lot of education and support and just to keep that skill set up and training. Great. I would assume too, some programs, you actually have other learners too, students, residents, fellows going through as well too. So we probably have a whole discussion about how do you effectively integrate them in a value-based model. Laura, while we're there though, someone had sent me a question about this very difficult time and decision around how long patients do stay on your service. And they ran into a couple of different cycles of transitioning to hospice in the last six months of life. And so each iteration they've gone through, they've kind of adjusted a little bit differently, but just wondering how do you figure out that best transition process and how do you operationalize it on your teams between palliative care and hospice? Yeah, that's an ongoing area of continuous performance improvement. But we have some folks, we know the patients who maybe are in a gray area or maybe they're on the fence. If we feel like their eligibility is, like we're not quite sure, are they gonna be eligible or not? Our providers collaborate directly with the hospice medical director to run through the case and kind of get the sort of approval before, because we really don't like having non-admits just related to ineligibility, but we try to never have that happen. And then of course your other non-admits will be for patients who, when the hospice team gets out there and they talk about it, they say, wait a second, that sounds scary and I don't wanna do it anymore, even though our nurse practitioner just had a great conversation with them. So for those folks that we think that's gonna be an issue, we try to, when we can, have an actual tandem visit with either the nurse navigator or the nurse practitioner with the hospice admission nurse, at least for part of that visit, to try to get over that hump and to help with that transitional process. And we can't do that for every patient because that's very time intensive and it's also difficult to schedule. But for those patients, particularly with those more complex or also with some of our different payer partnerships and things that we wanna make sure that that transition goes really smoothly, we try to do that. Thank you. And if others have thoughts or advice on that or perspectives, we'd love to have you throw it in the chat. Leanne, I was gonna ask you, you've done a lot of work in remote patient monitoring and started to play with that in your practice and would love to have you share your lessons learned and somewhat related to that, we're getting a lot of questions or someone had a question about what's everyone using for EHRs. And we know in home-based practices, it's hard to find a good EHR. So don't wanna be promoting anyone over anyone else, but we'd love to kind of hear what people are using to be helpful for folks. So Leanne, about the remote monitoring and then what are you using for an electronic health record? Sure, so remote patient monitoring a little bit different than the telehealth and certainly as we've already touched upon, not ideal for everybody. For example, we really only have 12 units and we utilize a partner that specializes in that. But we've found success, for example, patients who come on with hypertension, being able to make adjustments from a medication perspective and again, receive that objective data. Our in-care manager has access to it, the providers have access to it and we also work with ancillary pharmacists as need be for some guidance. But it's enabled them to then make adjustments to that medication regimen much sooner. The patient doesn't need to come back and our intent is not to have that in the home with that patient indefinitely, it really is for stabilization and then to be able to move that onto another person that might be in need. And just as was referenced, that also strategic partner participates with us with those patients during our IDT meetings because we get their feedback as well. And regarding EHR, our healthcare system happens to be on Epic as well as a lot of the majority healthcare systems in the area, which has been extremely beneficial. Again, just falling under the umbrella of our own healthcare system, our hospice is also on Epic and being able to receive information and look at that also with local and nearby healthcare systems, we all have access. Just a thought around your remote monitoring, what are the criteria that would trigger the use of the remote monitoring in your model? It would be somebody who's right, having kind of an acute exacerbation or challenge coming on cardiac, particularly like I said, the hypertension is what we've had the most success with, sometimes a little bit of monitoring like with CHF and in-stage, that gets a little bit more challenging as patients are able to navigate. And then for a service like that, this is a dilemma some practices have, is that something that you do inclusive of your practice? And so you carry the costs of that remote monitoring or do you actually get separate revenue for that or somebody else funds that for you? Currently, well, we do carry the cost, but certainly it is on the radar in regards to the reimbursement for RPM and incorporating that and making sure documentation captures that. And then also our billers having the knowledge so that we're not quite there, but I'm interested in getting there. Yeah, I mean, I think it's just a really good example where you start to see these needs and you start bundling some services in because you see it and you have to make those trade-off decisions, but figuring out how to pay for it, to be crass about it, but how it builds into your cost is that kind of conscious business planning decisions to make, but it's obviously a wonderful service. It's helping your team in a lot of different ways, but I just wanna kind of call that out as a dilemma, I'm sure. Just circling back around to Laura, this advocating for social work role, a lot of people are struggling with all these positions that are not billable still. You've done some work in that, so I'd love to hear your perspective of how you continue to kind of put the business case forward for the social work role as an example, and also just love to hear what electronic medical record system you're sitting on. Loaded question, Tom. The second one, I mean, the first one is very straightforward. I think that the social worker, I think what I see when, and working with some of the hospital programs and also the communities, of course, social work, yes, it's not a billable resource, and it's sometimes alongside spiritual care, the first thing to get cut. And unfortunately, I think that is a mistake because what they do, and I always describe them as like, they are like this intangible resource that somehow just makes things work. And that's the hard part is because you can't, it's hard to track and explain it in a specific way. We try to, and we try to have our social workers document on a log in terms of how many calls they're doing, how many family meetings they're doing, but it's really in the work that they do and meeting those needs, identifying what the family dynamics are, identifying what the barriers are, getting people transportation to their physician specialty appointment so that they don't just end up back in the hospital again. And those things, if you don't have them, I think physicians and nurse practitioners will try to do what we can, but we are not as skilled at figuring some of those things out. And then what happens is the care is just not as good. The quality is just not there. And I think that I try to describe it that it is raising the quality and it's also gonna impact the cost. So it's gonna decrease the cost of care by the interventions that they're doing, but it's also bringing the humanity of care to the patient and the family, which I think is just so incredibly important. But I do find myself not within my own organization, but when I'm trying to partner with payers and external sources, I'm trying to lead with that because I think that's an area that people tend to just cut, or they'll say, oh, well, hospital already has social workers. So we don't really need a specialty palliative care social worker, but you really do. You just don't know that you do, I think, or they don't know it. And then in terms of EHR, we are in the midst of a transition. So we're currently using NetSmart, which is, we basically home-grew our own palliative care unit within NetSmart, and we are in the process of moving to MyUnity platform, which is within that same umbrella. But we're also looking at GeriMed, so we're kind of in the midst of a lot of moving parts with that. And I think as your practice, as I know a little bit about your practice, Laura, you do a lot of work with a lot of health systems, you know, patients transferring back and forth. What's your interconnectivity like with them? I know there's a CCR transfer of data that can be approved, and you get a big wave of information into your system. It still takes investments to take that information in, and same thing going out. But wondering how you've connected electronically with your system partners. Bane of my existence, I'll just say. It is the connectivity. I think North Carolina is, you know, we are in the midst of expansion of a statewide health information exchange. And so in theory, that should help us all. You know, very early on in my time here, I was trying to say, why can't we just switch to Epic? Because everyone is on Epic here too, much to your point, Liana. And so it'd be nice to be able to. We do find that that can be a barrier for us, is that people don't see our notes, and they don't know what we're doing. And so you have to then over-communicate in other ways, which is, you know, I think everyone's so conditioned to just look in their record. It's like you don't exist if you're not in the record. So we do, you know, on the IT side, we do try to do the connectivity, the CCD transfers, and we've done a lot of work around that. We're trying to get as integrated with the HIE as we can. But it's not ideal. There's still a lot of gaps. And so we have to basically do, we get our own access to all the Epics so that we can see the chart. Some of our docs have privileges at some of the hospitals, so we can document if we want to. In some of our programs, they want us to document notes in, you know, it's like double documenting. I mean, it's just, it's a lot of work. So in my dream world, all of the EMRs would communicate to each other very smoothly. So I wish someone would invent that. But I think that, again, thinking about your design and your business planning, these are big lifts. These are costs to running your service and running your program that you need to factor in as you do your planning. And so there's a lot of interconnectivity to build. You might have duplicate entry, all those types of things. You might need a staff member to manage a lot of that. So I just want to acknowledge that, that it is not clean and smooth. And therefore you do have to put some infrastructure investment in to, to make sure that, you know, figuring out a way for your, your nurses or your providers going out in the community, they don't, you want them double entering if you can avoid it. So how do they get into one system? And you might need a team back at the office that translates that to, to the record. So important element. I'm going to keep going on a voice of experience because I think this has been helpful to hear even about electronic health records. And I was just wondering if Rebecca, you could share your perspective on either what we've been hitting on, on these efficiencies in your lessons. I know you had posted something up as well as what electronic record you're using on the interconnectivity with partners as well as internally. Yeah. So remote patient monitoring, I think has a lot of promise. We we're a part of a. Direct contracting entity for our primary care. It's just, we're just in month six of the first performance year. So it's brand new, but we have a we're using a platform called health recovery solutions and the DCE actually was able to get group pricing as you know, because they're very interested in seeing our DCE grow and obviously having more customers. So we got a pretty good price on it. It's still expensive. We started with eight units. I actually have one under here that keeps buzzing at me to remind me to weigh myself. So I'm, I'm testing it and I'm learning about it and I'm getting alerts. I have a family member on one actually, and I have to tell you the use case for high blood pressure is a perfect one. She's got cognitive impairment, mild dementia and she kept having high blood pressure readings when the once a week nurse would come in and take it, but we couldn't titrate her meds because we didn't know if she was taking her meds. We didn't really know what her blood pressures were, you know, in between the weekly visits. So now she's doing, you know, daily monitoring of blood pressure and we have a caregiver going in and what checking that she's taking her medication so we can actually see what's happening with that. So that's just one really good use case because we're using it for a direct contracting entity where we're in a shared savings arrangement with Medicare. We're hoping to actually identify patients who are at risk for hospitalization or re-hospitalization and using the RPM as a way to get us more real time data so that we can prevent acute care utilization for those patients. But again, it's brand new. So I would just say lots to learn. I posted that we use all scripts for our primary care EHR. It's fine. Not a big fan. We're in Epic town, so, but Epic is really expensive. So, you know, it's hard, but we do see, we think we probably would be getting more referrals if we were using Epic. I mean, at this point we're, we're really feeling like there may be an ROI down the road if we just bite the bullet. And the crazy thing is that we're on a different EHR for our hospice and palliative care. So we're on a bright tree for our hospice and palliative care programs. So we actually just within our small community-based organization are using two different EHRs, both of which no one really uses in our community. So it's just crazy. I mean, these are things that I, that, you know, my team inherited, we're trying to decide we're doing, you know, lots of exploration right now. The good news is that we do have a health information exchange across the state that has high adoption. It's called collective or pre-manage. And so we get real-time notification of acute care events. And you can also post notes in care manage that if, you know, ED case managers or social workers in the hospital actually have time to read, you can write things like call me. And, you know, they're, they're getting a lot better about doing that. You know, the COVID pandemic has put a wrench in a lot of our communication pathways, but, but yeah, so I think we're struggling with the same things and learning the same things as everyone else, but really good conversation. Yeah. We can all work together in our misery, sharing information, right. Learning it through the tough process. Russell, I want to shift to you in a minute, but I just want to acknowledge there's some questions coming through on billing for social work and licensed clinical social workers and others. And I don't know all of it, but CAPC has a lot of billing resources that are out there. I assume HCCI does as well too, but we can certainly try to get to some of those billing questions, but back to Rebecca's model of payment. What I heard from you earlier is you've got a, you've got these fixed payment, a monthly payment sitting on top of a fee for service chassis. And I think that's, you know, a blended payment model. It's just a good example of, you know, everyone sometimes jumps over to a full per engage member per month payment model. And honestly, in some cases, a lot of health plans can't even administer that effectively. So I just want to acknowledge as an example of you're trying to design the ideal program, but you might have a couple of different payment ways that you're going to get your costs covered. And it might be a model like what Rebecca was describing earlier. So I just wanted to go back again to that question about social work billing and others. Go ahead, Rebecca. Just to be super, just to be super clear about that. We actually have full, we have, we have two or three contracts that are full capitation. So PM, PM, and then we bill outside of those for like behavioral health counseling services. And a few other things carve outs, but mostly it's in the contract specifies what the PM PM actually pays for and what would be billed outside of it. And then we have several that are a blend and then we have 40% of our primary care payer mixes Medicare fee for service. And about 25 to 30% of that group is in a shared savings model, which is this direct contracting entity. So yeah, you kind of have to have a PhD just to, just to manage all those different payment models, you know, but it's worth it because it helps us to deliver the kind of clinical care that we want and still get reimbursed somewhat close to what our costs are. Thank you, Alison. You're going to share something I think. Yeah, I just I'll pile on to that multiple payment models. We're familiar with a few programs that are relying on fee for service billing directly, whoever the payer is for the patients, but they're in arrangements with another provider. Usually the ones I'm thinking of are in ACOs and they get, I'll call it almost a grant, but a lump sum payment, to be available and work collaboratively with the ACO and, and that additional revenue goes to supporting some of the things we're talking about, like social work chaplain, the things that are are a stretch to cover on the billable providers fee for service. So I just wanted to throw out that and someone saying, do you share any savings with the ACOs? So there's two organizations that I'm thinking of that do this. In this case, the ACO is pretty much bankrolling the home-based care provider on the expectation that home-based care will deliver the shared savings. So the ACO keeps the shared savings. I probably, let me think a little more. I can, I'm sure I can think of a program that shares in the savings as well. The, the, the one I'm mentioning or the two I'm mentioning, just get the payment. Russell, your, your thoughts on electronic health records, as well as team efficiency. So electronic health record, we are, we are, we have the benefit now of mostly all being on Epic, but I certainly remember the early days of multiple EHRs and double documenting and scanning and other EHRs and very much a time stop on productivity, but also something that requires some attention if you are in that model because the communication is so key. I'm grateful that we're all at Epic. What can I say? It's really streamlined the communication. When you think about your community partners though, and you might be working with others, you've got to work with and transition information back and forth as they transition out of your program or out of your system or come in. How does that operation? We've only got a few. We honestly, we only have a few of them. One of them is a medic, a Medi-Cal managed group in, in California. We have the SB1004, which is the home-based Medi-Cal palliative care. So those, those contracts, I think this kind of goes back to that earlier conversation about agreeing to contracts. And we find that those take a great deal of additional manual work that I'm not fully convinced are worth the trade-off, but is a larger sort of organizational decision to participate, especially with our pediatric population, because so many of them are Medi-Cal recipients, but we're having to do spreadsheets and time logs and all kinds of stuff that are pretty labor intensive. All right. So there was a question that just came through, and I think there was some interest in hearing more about shared savings arrangements and palliative and how savings are measured. And maybe I'll pause for a minute, Allison, and get your thoughts. We've got a point of inflection here. We can move into a break and then we're going to come back and start talking about really the patient engagement side of all this and, and the, and the stratification piece. Do you want to pause at all of this and share that, or do you want to move that into maybe a topic for the office hours afterwards? I'll give a quick answer. And I'm not aware of any arrangement where an ACO has calculated the shared savings that are attributable to a home-based program or a palliative care program, and therefore set up a payment based on those calculations. I also would discourage you from going down that because then you start going to count you, you're, you're on a slippery slope where you're calculating, oh, well, Tom's costing us too much. And Allison's, you know, we, we made $5,000 analysis and it's just not true. It has to be looked at at a population and an organization approach. I, I, I would, that's my answer. Unless the VOEs have experienced where you've gotten a calculation of shared savings that were due directly for, to your program. Go ahead. Yeah. I I'm, I'm not entirely sure. I'm understanding exactly the question, but when we were, when we were involved in the independence at home demo for home-based primary care, we definitely every year. We, we didn't know in advance, maybe that's what you're asking. We would find out and exactly how much we were earning. So it's different than an ACO model. Right. I'm sorry. So if you're going directly with a payer, then you do have calculations where you're saying this is, this is the target spending and anything below it is shared savings. That's directly with the payer. So yes, that's true. I guess I was reading the question as the ACO has the relationship with the payer and the ACO is then paying for home-based care or supporting home-based care. So yes, thank you for, for doing that. The shared savings are usually based on a target expectation of what the population will cost. And then if you're in that arrangement, the entirety of the shared savings is yours. Can I just ask that Tom or Alison, I, there are some really good questions that seem to be directed to me, but probably other VOEs around how just this combination of fee-for-service and PMPM. And I was going to try and answer them in the chat and maybe an office hours or a question. I'd love to be able to share a bit more detail about that, but I'm worried that if I do it in the chat, it's just going to be even more confusing. So just, just an observation, I'd love to answer, but I just, yeah. Well, you know what, we've, we do have a few minutes right now, and I think it would be great if you wanted to share a little bit more insight. We have a little wiggle room here to go ahead. That is important questions. I think people have been raising them. So would you, would you want to go ahead and take a few minutes right now and just share some of your more detail? I'm happy to, I just didn't want to take too much time. Yeah. Why don't we go about three or four minutes? We're up for a break in about five minutes. So let's go ahead and have you do a little bit more detail there and then we'll take a break and we'll come back in and Allison to finish out in the last portion. Okay. So go for it. So Laura asked to clarify, we do provide one clinical model. One clinical model. So I'm talking about home-based primary care right now. So we do provide one clinical model regardless of payer, just because it it's too administratively burdensome and it's not good for the patients. And it's not good for the morale of the staff to have to shift based on the payer. So it's one clinical model where we stratified by patient acuity, and that helps us understand how to use our team resources. When we have, we don't have any straight fee-for-service contracts anymore, except for with Medicare, which is just a different ball of wax. So with all of our local payers, we either do a straight capitation. So a monthly PM, PM for all primary care services, or we have a blended mall where we're encountering fee-for-service claims. And then they're giving us an additional capitation on top of that. And that really helps us to provide the non-billable services like the RN and the social work field field visits and the chaplain. We are starting to get more savvy about the fact that even in our fully capitated arrangements, there are services that really weren't included when we did an original, an original contract when we were negotiating. So for instance, we're just building a behavioral health and primary care program right now. We're hiring an LCSW. And she's going to start billing behavioral health counseling codes that will be paid for outside of our PM, PM. I'm trying to think of another really good example of something that we would build. There's certain procedures that we bill that we'll get reimbursement for the COVID vaccine. We'll now get reimbursement for outside of our PM, PM, but mostly everything's in with just a few clicks. Everything's in with just a few carve outs. The other question that I think is important is Laura was asking, well, you know, for those PM, PM contracts, are you saving administrative burden because you don't have to actually bill or encounter the fee for service claims? Unfortunately, we still have to encounter the claims because the payers want to know what, what they're getting for the money they're paying us. And also because for Medicaid rates are set for Medicaid plans based on the services that you provide. And so the Medicaid plans need to encounter those claims to the state. So the payer basically zeros it out and pays you, they give you a zero remit back, but they want to, so we're still having to send the claims. It's just that we don't have to be so prescriptive about how everything is documented. And if we miss CCM minutes, it doesn't matter because those CCM minutes, you know, aren't going to get paid anyway. So I would say we do the bare, sort of the bare minimum. I mean, on, on the PM, PM contracts, we just don't have to worry about it. We don't have to worry about not getting paid for all the, you know, nursing and chaplaincy. So I I'm hoping that that helps. That's wonderful. Rebecca, great granularity. I think. Yep. I think what we'll do too, is just to remind everybody too, that our voice of experience effectively be available afterwards to people that have more detailed questions for Rebecca or anybody you'll have some smaller one-on-one time with them. So we're going to take a five minute break. We got one last push, one last section 46. So if you could come back at 46 after the hour and we will finish out the last section and then move into summary points. Okay, folks. Coming back for the last stretch. We are shifting into the conversation about stratification, engaging populations, how do you manage the use of the team with your stratification, all that around managing engaging populations and really the active management arm of managing all of the populations. With that, we've got a couple tools out there. There's a patient engagement guide and also some stratification considerations, our tools that are available to you. With that, we are going to hand it over to Allison to lead us, this last big push, Allison. Fire it up. Thank you. And I also will take this opportunity, yeah, this is a long day with a lot of information, a lot of talking heads at you. So what we're hoping is that you're taking what you can out of today. The resources, again, Melissa, maybe you can go back one slide. The resources are on every slide and we'll make these things available to you. So you can dive in a little deeper. I wanted to say that. And I also wanted to say five-minute breaks, at least for me, were extremely short. So if you want to stand up and stretch, cat, cow, now's the chance to. All right. Now we can go forward. So I wanted to talk about some of these efficiency things really come to the old adage, the right patient at the right time with the right service. So how do you get the right patient? I also remember an earlier comment in the chat that you set everything up, everything's great, and then the clinicians weren't referring. I'm going to put in a plug to think about using data to find patients and maybe relying less on pure clinician referral. At this point, you don't have to build a sophisticated algorithm. If you're working with a population manager or a health plan, they're going to have the sophisticated things and let them do it. If not, you should target a short set of diagnoses that you know your program could work very well with, and then start looking for people with recent utilization. It also helps with engagement if you target patients that have recently been to an emergency department or a hospital, if you know that information, if it's in the HR. I know it sounds like there's a lot of folks struggling with not having the ethic that the hospitals have, but to be able to find the right patients will avoid all the problems that Laura was talking about with the no-shows and the inappropriate referrals, and it also ensures that you can be efficient because the services that your program is set up to deliver are going to go to the right patients. Next slide. So how do you find them? As I said, the demographics risk scores, when you have them available, are really great in hospitals. They tag patients with mortality predictors, and if you're working with a hospital, you can be able to get that. Rebecca, I think your program is genius at this, that there are certain prescriptions to look for that are a good indicator of a need for home-based care. I mentioned the past utilization, and when it's available, functional or cognitive impairment to pick up on that data and screen out first by diagnoses and then by some of these additional factors. Next slide. Okay. Now, this is perhaps, well, there's a lot of challenges to this. Home-based care is just challenging, period, but this would rise to the top, which is engaging folks, and earlier in the chat, someone was saying their outreach coordinator called and got an earful about this being spam, and particularly in this day and age and particularly if you're working with older adults, I read AARP magazine religiously, and the lesson I take from every magazine is everything is a scam. Don't answer any phone calls. Don't respond to any texts. So it is really challenging. A couple of things I'll add to what's on the slide here. The first is that if you are working with a provider organization, or even with your health plan, if you have a relationship and you're running your program from a relationship, ask your partner if you can invoke their name. So if you have the availability, you can send out letters ahead of time, and I'll give an example. Dear Allison, we are a program that supports patients like you. We work with Upper West Side Medical Group, and they thought it was a good idea that we get in contact with you. So you invoke the permission of the practice that you're working with. Usually if you can, sending a letter ahead of time, again, in this day and age, if you can, that would be of use. I know it's not always possible. Of course, if you're getting direct clinician referrals, then name that clinician when you reach out. Dr. Galtieri-Reed suggested I call you, not, oh, I'm calling you and I'm from this program. Don't do that if you don't have permission and you're not in that type of relationship, but it does help to open doors. The second thing is to, we did a lot of research with some of the more successful engagement organizations, and really hitting on the access and convenience pieces of what you're bringing to the table. I have a list here of some of the benefits that seem to work well with consumers. Again, only say these things if you can promise. We can get you to a team without delay. You can call somebody 24-7. It's free. We're not asking anything from you. This is the added layer of support. Someone's here to help you because we know healthcare is complicated. These are some of the things that we've learned. Don't fire hose them and include a lot. Same thing in your introductory letter. Hit on one or two because when you start adding a lot, it comes across as salesy. These are some of the ideas of how to engage patients. Another thing that works well, like we were saying earlier with your partners, let's just pilot. Let's just try it. One thing you can say is, look, I have a nurse that's going to be in your neighborhood on Thursday. Why don't you just meet with him and see what you think? Again, there's a lot of consumer research behind this that people always like the idea of just trying something and that they can back out at any time. You're not making that point that all you want them to do is to try it. Next slide. This is the idea of stratification. This is back to the efficiency piece. Whether you're working with clinician referral or data-driven lists, you're going to have variation in who the patients are in terms of their acuity levels and in terms of what they need. One of the very first things you should do after you assess is stratify them. There was a chat conversation or breakout, I can't remember at this point, but about, oh, well, what it really means is that we give fewer visits if it's a lower price point. I would argue that's not true. I would argue that you take a look at your population, and yes, some people get fewer visits than you might otherwise want, but there's going to be folks in your population that should even get more visits and more touch points because they're the ones that are the highest risk. The idea of stratifying is that even if you're getting a fixed payment across an entire population, that population has variability, and if you could stay on top of what their needs are and figure out what we call dosing the intervention, figure out what they need to be safe and stable. I think that's a really important way to manage your efficiency within fixed payments. Next slide, please. Allison? Mm-hmm? I'd just call a commentary for a moment. That just struck, I think, when we were prepping the other day. We had this really robust conversation about sometimes people would say, well, once your patient's in, you've got them stabilized, should you go to a different and lower payment because you settled down? I think this is an example where what we were talking the other day on the phone was keeping one payment because you're going to have a lot of that variability, and you want to make sure that the payment you're receiving covers all the different types of variability. I just want to connect the dots between stratifying and knowing your population well to run it efficiently, also thinking about the fact that also helps you realize the variability you're going to have to manage within whatever fixed payment you get. I just wanted to connect that dot for a moment. Yes, thank you. Yeah, and there was a comment in the chat earlier about, well, telehealth's less expensive, so we can pay you less. So it gets to the point of who gets to really keep or capture those savings of if someone's more stable and they're lower down, the program still needs that payment to manage the entire population. And the same thing with telehealth, if someone's getting more telehealth visits, you need that payment to support the entire population across all types of visits. Rebecca, you said earlier that you reassess every six months. If there's time, I'd love to hear your comment after I get through the next couple of slides. I've heard it should be two or three months, again, so you can be able to dose effectively. But I'd like to hear how you do it at six months. Next slide. So it's easy to say, okay, go ahead, stratify your population, but your program is run by clinicians with different opinions and different ways of doing things. So it's not going to be fully an accurate way that folks wind up in your high, medium, and low stratification. In general, you should try for the preponderance of your population to be in the medium and try to keep the tails smaller. So again, that's easier said than done, I realize that. But if you could only have about 20, 25% of your program on that high intensity, which means some strong clinical interaction at the beginning. And then I think we've talked a lot about this, but how you handle the low risk, keeping them on the program tone, just as you said. But disenrollment gives you a chance to be that reliable resource and not have a waiting list, too. So you'll have the capacity in your program to continually take on new patients. Not a great answer, but considerations on both sides. And then, oh, as I said, the right schedule for reassessment. The things that CAHPSI has been gathering seem to say three months is the right rhythm. And if you can pick up a change of condition, obviously you want to respond quickly. Rebecca just said six. So there are probably different reasons for different assessment schedules. Next slide, please. So getting back to patient engagement, I took the phrase, the three-call problem from Christopher Smith, who is now chief clinical officer at Prospero, which is a national home-based care organization. And I really like this way of thinking about patient engagement. So the first call is, yes, that hard one where you're perhaps cold calling them or you're explaining that you have a referral and you have a great service to offer them. So if they're willing to see you, that second call should be, you know, your check-in call. Okay. We've assessed you. We've got a care plan here. We're visiting you. You need to use those first two encounters to get enough trust so that if there's a crisis or if there's a problem, they call you. That, again, these are people, as Tom said, they're getting a lot of calls from a lot of programs. They've been through the ringer. Personally, I'm going through this with my mom now, and yeah, I'm becoming more and more distrustful of folks who are trying to take care of her. So if I see a crisis and I call and I get an unsatisfactory response or I feel like I'm not in safe hands, I'm never going to call again. And if you're trying to produce value for a partner, it means I'm going to be running to the emergency room to make sure that my mom gets the care that she needs. It means that all the great services that you have to offer the patients and families aren't going to be taken advantage of. So just really, the point is when the patients and families call, really do your best to respond with a good clinical plan of care that addresses the issue they're calling about. Next slide. I think variations on a theme, this is coming up in every section, hearkening back to Lynn's and this is probably one of the key variables that we have you put into the spreadsheet when you're calculating your program costs, but it's a choice for you to make for your program, but short term, you could have impacts on patients if you do have a great way to transition and a great additional resource, either a good steady primary care that's not home-based or hospice. The other, though, ongoing care, if you're doing ongoing, this is a patient that you're doing primary care for and they're on your program, keep that idea of the check-in calls and especially tuck-in calls. So Russell, I think you said earlier that your Friday is your clinician's front load earlier in the week and have time for team calls on Fridays. Try to use your Fridays for those high risk and maybe some of your rising risk to check in on them and just make sure, do you have all your medications? Do you have the services or what's your current symptom burden level? So do some check-ins before the weekend. So to the extent you can recognize crises early and divert it before a long weekend, you can be in better shape. Next slide. Oh, so that's it. I know that was a lot of hard, I keep saying this, easier said than done, but this goes to the heart of operating a quality program, and if you haven't taken the FEMA way, that it's putting your resources where you can deliver the quality so that your partner feels confident they can get what they're looking for out of your program. So I think, you know, just to kind of frame up a couple of these things and that you're referencing, you know, the concept is, is that you've got a population that you're taking care of, you're thinking very clearly about best use of your team, stratifying those patients, dosing the service, it's all about that kind of active management concept. I'm going to go back about 30 years of my health care life here, but, you know, really thinking about the management of those patients in this population and, and really, you know, the examples that I know this happens a lot in hospice and other services as well too, but, you know, kind of that Friday tuck-in, like you're thinking about which patients are at risk of going to the hospital this weekend, have you checked on so-and-so, where are you, these are all elements of having those operational structures in place that make sure that you can stratify, you know who's at high risk in your panel, who you're trying to work with and actively manage them. I think, you know, just to kind of play around with our time here, we could do breakouts, but I was wondering, it might be good to hear a little bit more from a few of the faculty here on your experiences, and you were asking Rebecca, I think, a question earlier to have her share, and maybe let's go ahead and have that discussion now, and then we'll bounce over to some breakout just to give people a chance to learn from each other, and then we'll come back in, but Allison, you want to go back to Rebecca's question or your question for her? Sure, I have seen programs, and I know we've seen one program, we've seen one program, but when you're really staying on top of your population, the key is formal reassessments, and again, what the consensus seems to be that's coming to CAPC is three months, so could you comment on your reassessment processes and how you manage that? Yeah, so I think part of this is that I was mostly talking about what we do in primary care, our palliative care program reassesses much, much more frequently because they're higher acuity, but I did pull up some slides to remind myself, because we presented at the academy last year about our patient stratification process, and it actually is, our re-stratification criteria for our home-based primary care program is that they're stratified initially once they've been seen at least two to three times by the provider or the care team, and then they're re-stratified if one of three things happen, either their resource use, and we measure that by CCM and CCCM billing or encounters, and their stratification appear mismatched, so essentially if the patient's needs, as indicated by ways that we can pull out of our EHR, are mismatched, then we're going to look at the patient again and re-stratify them, and this is across a panel of 1,500 patients. If they're identified as being a high user of hospital services or they're at risk for that, so you know, we have high, we have IDT meetings, so team members can, and any team member, the third criteria is a request by any team member to re-stratify them using our tool. We do, we are now using a data platform that has a predictive model engine behind it, and it basically has certain triggers, so at risk for hospitalization, potentially hospice eligible, and just generally high risk, and so those are also triggers that will allow us to know, you know, maybe you should look at this patient again, but I would say, you know, one of those three things probably happens more frequently than ever, every six months, even in our primary care program. The other thing I wanted to just mention is, what are you actually stratifying on, so what are the domains that you're, that you're, whatever tool you're using, and I just thought I would share, our patient stratification tool was developed based on a validated tool called the Minnesota Complexity Assessment, but we kind of modified it for our patient population, and it basically asks 10 questions that are, and there's a score of zero to three on each one, and the 10 questions hit on basically these domains, symptom severity, treatment challenges that they're having, active substance use, behavioral health symptoms, the organization of their care, which basically means, you know, how many specialists might be involved, how many systems are they seeking care from, what's their living situation, in terms of safety and stability, what is their patient, caregiver, family, or team relationship like, what is their caregiving adequacy, financial resources, and then communication, which really looks at, are there significant communication barriers happening in the care of, taking care of the patient, so those are sort of the domains, and then there are very specific questions, and then a score of zero to three, and then we stratify them into essentially low, medium, and high, similar to what Allison said. That was really helpful, and there's a comment in the chat from, okay, no, I just lost it, from Dave, about this idea that when you look at utilization, the things that are driving utilization, complex psychosocial needs, and maybe all of our VOE, if you can comment, Rebecca, your program specifically specializes in the care of psychosocially complex, so maybe Laura, and Liana, and Russell, I'd like to hear what you you think. What I'm suspecting is that this high need population of people with serious illness is increasingly comorbid or further complexed because of high psychosocial needs, and it's getting more difficult to run a program that doesn't incorporate some care along those aspects, but I'd love to hear from you guys. Yeah, Allison, I would agree that I think it does seem like, and particularly I think in the midst of this pandemic and the sort of the impact that that's had on a lot of communities and mental health and substance use and serious illness, there's just, there is a lot of overlap. I think we want to try to provide care where we have the most expertise, so if it's purely, you know, a mental health issue or a homelessness issue, you know, that's going to be harder for us to manage, but I think finding ways to partner with those organizations that are expert in those is really critical, and I do think that, you know, we've talked about, you know, how can we incorporate psychiatry or mental health services better within our organization, and we haven't figured out the best solution for that, but we do have, like, we have a psychiatrist on contract that we sort of collaborate with in certain cases, but it's not really to the degree that we would need it in certain situations, so we try to divert, you know, if something's purely kind of chronic pain or significant substance use related to that, trying to find resources to help that person, but then if they also have existing serious or life-threatening illness, we also try to provide the services that we can provide, so it's really sort of in tandem, trying to pull out the areas that we can help. That's great, so back to that idea of you're not saying no, you're saying let's look around our community and figure out how to make it work. I'll add a little bit on that. So, for us, in regards to stratification, I guess kind of one of the benefits of participating in the value-based alternative payment model that we're in with the state, they actually provide us a stratification of our panel and where they break out. Definitely high acuity, definitely higher in the tier four, but that's not the only thing that we're in the tier four, but that also helps us explain some of our outcomes back to the healthcare system where other primary care practices have less acuity and might do a little bit better in utilization or actual percentages, so when we take a look at that, that's still beneficial. The, you know, mental health, the behavioral health, just the social determinants of health, which we've all talked about today, a couple just points that continue to resonate. Social work, you know, again, we know we can have the best clinical care, but if the electricity is going to be turned off, there isn't any food, there's no support in the home, that's pretty irrelevant, and you're still going to have back to utilization of a healthcare system, so, you know, again, advocacy for whether that's community resource, you know, who can stay in the home, complete paperwork, which, again, is not a social worker and certainly not a provider, but there's a lot of other things that need to be done just to even sustain the person in the home to receive the care that we're trying to deliver. And then the mental health, I think all have seen certainly an exacerbation over the last 18 months. It was there before, it has been compounded, and again, trying to, similar to Laura, contract with some existing behavioral health, but oftentimes we might come across something upon initial referral that's beyond our scope, and we have to share that, you know, rightfully so, and occasionally we will have a patient who does have, again, an acute exacerbation, and then our team is kind of having to reach out with network, our providers still being the primary, but they're, you know, co-managing now and reaching out with somebody within the healthcare system. Again, that's not sustainable, it's for an acute short period of time, but that's how we've been navigating lately. That's great, that's really creative problem-solving too. Lena, could I just ask you in your, you said the state, you've got that criteria that they're using to identify patients. Number one, could you have more granularity on what, again, some examples of what the criteria is, is my first question, and my second one is, is when you get those referrals in or get those patients identified, is it like a 50% hit rate, or like, are they really patients that are profiling appropriately? Because this debate about clinical data, administrative data, and the real old-fashioned, you can look at a patient and see the need, but it's not coded anywhere, is always the debate. Just wondering what you run into. You know, and I will share, I'm not, you know, extremely well-versed in being able to speak to all of the metrics that they use to do the stratification. I just know that we receive the information of a, you know, snapshot of our panel at a given point in time, and the percent, and sometimes even down to names, and those that would be the highest utilizers and highest risk is what they provide for us. And when we, you know, compare that back to what our team experiences, definitely it's right on the money. Great, thanks. Can I ask a follow-up? Leanna, keep you on the spotlight. So, they're running lists, how, could you give a color story about how your team engages the patient? Sure, that might, those are, you know, sometimes, to your point, and we've talked about, there are scenarios where the patient's going to go to the ED and or be admitted, because, you know, all efforts have been made, but that's the best next step. And so, when we're aware of that, then sometimes it's the, we know that we're going to be touching base with them on a weekly basis, and or that we do with our group of providers, we are able to provide our own 24-7 triage and provider call. So, sometimes we're teeing people up and sharing, you know, what happened to Mrs. Smith today, if that call happens to come in overnight, these are the actions that have been taken. And then, if we do have a call, it also is queued up for our provider to take action again in the morning. But it's kind of, you know, close follow-up, again, knowing that they're hit the radar, not only for us, but, you know, for the healthcare system and to see what we can do. And sometimes, again, we try our best. And I'm going to try to hang on to you a little bit further. You might have said this a minute ago, but how do you also use that to think about, like, there's multiple different services that you might offer, and that kind of that one front doorway entrance on the way in, and then triaging them to the right program. How do you solve that issue? Great point. Because, again, what I should have mentioned is sometimes it's also, when's the last time we revisited, right, the plan of care conversation and, you know, taking a look at transition. So, a benefit of being embedded within the system that we are and the continuum of, you know, care for seriously ill is that we are able to transition to hospice should that time arise. Sometimes our providers actually move with them as AOHR, and so sometimes that's nice because we're able to provide the patient and the family some continuity of care. Great. Russell, we'd love to hear your perspective. I know you've done a lot of stratification models and such. I wonder if you could give some detail on how you're using it and how you're deploying your teams based upon that. Yeah, let me back into a couple of the conversations that have been swirling around. So, with regard to our approach to mental health and psychiatry, I think our approach is very similar to Laura's. We, what I don't think has specifically come up yet is that with our largest payer, our patients are actually identified through an algorithm. So, when we started that process in 2015, we've tweaked the algorithm several times. But initially, psychiatric, primary psychiatric diagnosis standalone was kind of thrown out because we didn't feel like it was appropriate or that we had the skill sets. However, it is part of the comorbidities, and I'm sure as we've all admitted to that the past year is certainly an increasing area of need, both with regard to mental health and psychosocial need and areas of support, but also with certain populations meeting the basics. So, access to food, shelter, that sort of thing. I don't know if you want me to speak to it, Allison, but our contact reaching out to patients and families has also kind of evolved over time. Oh, please. On any given month, we get about 40 patients that are identified through the algorithm. Those patients before coming to us are sent to the primary physician, who will say yes or no. In a perfect world, they will have some sort of warm handoff. It doesn't always happen. So, we've kind of, we've been through a lot of variations with that process. I'd say by now, our people are pretty good at that initial phone conversation, kind of nuancing that and getting their foot in the door, I believe. Yeah. I'm sorry. So, can I ask, so the fact that you ran the list through the currently listed primary care and they said yes or no, do your outreach staff then say, oh, well, Dr. Kiefer said it's okay to call you? Absolutely, and then over the course of time, we're also getting a lot of direct referrals from those providers. So, it's a combo. And then I believe we're doing two call attempts, and then if we don't hear back, then we'll send a letter. And then if there's no response to the letter, then it's closed out until a new referral is generated. With regard to stratification, Tom, very similar to what I've heard, and also came up in our last breakout group. In fact, I have a couple of people in that group that if you ever need more names for your voice of experience, there's some pretty sophisticated people in the group. So a lot, I'm finding that many people use the kind of one, two, three level. So our patients are also listed in level of acuity. All of our patients when they come on service are listed as a high need level one for at least a month so that we can establish the relationship. We learned early on as well that unless we're doing a lot of investment and upfront time in the relationship, then we don't get called as often by those patients who may then choose to go to the hospital instead of either calling us or remembering to call us. And then two and three, again, I think Allison, you spoke to this really well, but if a patient is hospitalized for any reason when they return home, they're placed on level one for at least a month. And then that is assessed at each visit and then also at our standardized review time. So I'm curious. I actually like, I think that's very elegant to keep people in the high category when they come on and when they come out of the hospital. I'm just curious, roughly what proportion do you have people in your high category? I would say it's similar to what you showed us, probably between 20 and 35. Okay. Oh, Tom, you're on mute. Yeah, I'm asking myself great questions. Actually, we actually have some questions coming in and I thought we'd kind of shake it up a little bit and see if, for example, Bridget, I was wondering if you might be willing to take yourself off mute and actually asking your question to our group here. Oh, of course. Would you mind just, great. And you mind introducing yourself where you're from and then launching your question? Yeah, sure, absolutely. I'm trying to take myself, get the camera, but I'll keep going. There we go. So yeah, I'm Bridget Earle. I'm from Atrium Health, the service line medical director for our hospice service line and our community-based palliative care program. Atrium Health is a larger health system here in Charlotte, North Carolina. And so my question is, so in the midst of our program, we are going through a transition where we are combining our home-based palliative care program and our SNF palliative care program into one cohesive program. And so that's how we are really growing for 2022. So my question is, we're looking at, how do we anticipate our growth? And one of our strategy is using the high-risk home health patients as a trigger for a community palliative care consult. So my question was, how do you use that in terms of high acuity and communicate to the referring provider so that you can actually see the patient? So that's kind of one thing that kind of came out of our work group and I'm curious how this group would handle that. Which one of our voices of experience would like to weigh in on that one? I'll pick on, Laura, how about you? Yeah, I think, I mean, it is a great way, I think, to grow the palliative care program. And we have a home health program as well. And there's a lot of overlap between the populations that are served because our home health patients, it's a pretty small program, but it tends to be a sicker population. And so there's a good overlap in the home health program is a great referral source for palliative care because they'll be out there and say, like, this patient is really struggling or really need goals identified. They may not have the time or skillset to do it. And so they will kind of reach out either to us or they may reach out to the primary care physician directly to request a referral. We haven't, I mean, we, our nurses are pretty comfortable with reaching out to the primary care offices. And we work with a lot of the providers in this area. And just saying, the home health program reached out to us and said, it sounds like your patient's struggling and just, you know, this is what our program is. If they don't have familiarity with us, is it okay if we go out and do a consult? I think some of the primary care in the past have been worried that we're trying to steal their patient away from them. And so really clarifying that, you know, we're here to co-manage and we will be communicating back with you any findings. But I think having that connection to the home health program is really a great idea for building the community-based practice as well. If I can just tag on to that last point from the health plan perspective, there's a growing contingent of health plans who have recognized what you have, Bridget, that the best place to find people in need of home-based care is those who are already in a home health episode. And I think in our breakout that came out too. So it's the right pond to fish in. I just want to stress that. Russ or Leanna or Rebecca, you guys want to weigh in on anything there too or add or? A quick question, Bridget. So from a skilled nursing facility, are you entering or you're trying to expand from there? Good question. So we are looking to expand more in the home than in the skilled nursing facility space. And these two programs currently operate in two separate areas in atrium. So we're really trying to bring both programs together under one group, which is post-acute care, if that makes any sense. So both programs are managed separately. I managed with the few hospice leaders, the SNF palliative care program, but our what's called advanced illness management program was managed by a completely different team. So the goal was through strategy, but then our system bring those two teams together, look at the various system-wide goals that we want to achieve so that we can have a cohesive plan for community palliative care as one whole. Does that make sense? Yes. I can just, so we conduct work in skilled nursing facilities in two spaces. One is we have a palliative team group that does go in to do palliative consults only, but they are in different facilities than our attending and our medical directors. However, we also have the home-based practice and sometimes there's also an acute exacerbation, even from somebody from our home care practice goes into the hospital. Hopefully we can reconnect and pick them back up in a SNF where we are and be part of even the care planning process and working with social work. And then it's also icing on the cake if you're able to have any type of interaction or conversation with family at that time as well. That's helpful. Thank you. I can just share that most of our community-based palliative care referrals are coming right now from our health plan, one of our major managed Medicaid and dually eligible health plans, as well as from community providers, PCPs, a lot of specialists, a lot of oncologists. I like the idea of a partnership with a home health agency. We don't actually operate home health, but a lot of our home health agencies also have palliative care programs, but they're not really focused on a safety net population like ours is. So I actually just wrote this down as an example of something that we might look to as well. But I will say that the payers have definitely been sending us a lot of patients. I was wondering, Tina, you had made a comment earlier about the clinical review and the assessments, your secret sauce. So I was wondering, Tina, if you'd be willing to hop off mute and just share your insights and perspective on that critical point you've found or wanted to share. Sure. So predictive analytics is really a great tool depending on, from my experience and what we do at my company to kind of broaden your net. I mean, you can set up for any kind of algorithm and predictive analytics that you really are trying to capture to make sure that you're meeting needs and that you're capturing a population. It might be the top one, it might be the top three, it might be a certain patient focus, but I think it's really important. What we put in place was a clinical review of everything that that algorithm kind of spits out, if you will. And the way we go forward is that any patient that the algorithm or the dataset may identify that would qualify for our advanced illness model or our palliative care model always gets that clinical review. And our clinical review consists of an assessment that kind of captures things specific to the patient that the data may not capture. Their frailty, their risk that you don't see, that you see outside of claims or that you see outside of HCPCA codes, social determinants of health that could be risky. So all of those things, I think, are key things. And what we have found through our own experience is we tend to hone in on more patient needs that way and you get a more specific patient population and criteria to make sure you're bringing the right needs to those patients. And it's really gone well with payers to say that because it's not just depending on those data and those analytics to make sure that the appropriate patient is getting the services that they need. Yeah, I just wanna chime in. Thank you so much. I agree. I think that that double punch of data and clinician referral is really the best way to go. I perhaps was speaking to some programs that rely on clinician referral. And I think the concern about relying solely on clinician referral is they're perhaps not thinking of their full panel, especially the ones that are relying heavily on the ED and whatnot. They might not even be seeing them enough. So that they're top of mind. And there's been a number of studies and clinician referral for home-based care is somewhere between 50 to 60% getting the spot on patients. So I just wanted to put a fine point that what you're saying is absolutely right. The data alone is insufficient, but my point is that clinician referral alone can also be insufficient. Others wanna comment on Tina's perspective? And thank you, Tina, for sharing. Russell, do you wanna weigh in at all? Pick it on you just cause it's kind of fun. Yeah, I know you are. I don't know that I have much to add on this one. Sorry. Yeah, it's all right. Anyone else? We had another question from Dave. Any advice on... Actually, Dave, let me let you ask that question. Dave, unmute yourself and love to hear your voice and see your picture if you're up for it. Great. Oh, you're a little bit faint. Forgot to switch my microphone on. Sorry. Hi, I'm Dave Tran from Palo Alto Medical Foundation in the Bay Area. I think one thing that we've been struggling with is, and we're coming from a slightly more mature program, is now that we've built up our panels and we're trying to scale in sort of a changing cost environment, we've had a really difficult time trying to figure out how to discharge patients. One, because the culture of our program isn't used to letting go of patients who are stable. And two, we're trying to figure out how to do this tactfully so that we don't undermine, first of all, the patients, to make sure that they're comfortable coming back to us when they need us. They're referring providers to make sure that they feel like they're getting the services they were hoping for from our service, as well as sort of other stakeholders like payers. So words of advice or counsel from folks on that. I mean, I think that is definitely a challenge. And we certainly, we have some patients who we've probably been following maybe almost the whole time I've been here, which is going, I'm in my eighth year. So there's some patients that it becomes very challenging to discharge. And I think especially if you are, if you have a co-management model and you're doing any kind of prescribing, that becomes even more challenging, particularly if it involves opioids, because I find that a lot of the primary care that we're collaborating with, they don't really want to take that part back sometimes. So I think, you know, when we are looking at our co-management process for our palliative care program is really looking at the patients. We don't co-manage for all of the patients in terms of prescribing. We're kind of, we try to be thoughtful about who we are getting into the prescribing relationship with. And those folks are more likely to be on the later stage of their illness from a prognosis standpoint and, or more homebound and have a lot of difficulty getting back to their physician. So that, I found that to be a barrier, but otherwise, you know, what we do is we have, when folks are getting pretty, you know, stable in terms of their clinical status, we talk about, you know, how our visits are gonna get more spaced out. And then at some point talk about how we are gonna put, we're gonna, we have what we call a stable list, which it's actually in the midst of being transformed because we realized people were staying on the stable list also for a very long time and just getting phone calls. And it just becomes hard from, our program is actually pretty large now. I think we have, you know, 800 active patients, 7,800 active patients. And then we had a stable list that was like 300 patients or something. So we actually do a, now we're going to do like a one-time phone call after we've discussed that, you know, we've kind of stabilized, we're gonna, you know, we always say, we're always here. If you need to call us back, if something changes, if you go to the, you know, your condition changes, you go to the hospital or you have a question, you can always call us. And we also send them a letter and send the primary care a letter too, as well as communicate with our notes. But so far we haven't had too much resistance to that, but there are some folks who do want to hold on to us and some folks who we want to hold on to, I think too. Ray, you put some great advice in the chat. Do you want to unmute yourself and? Sure. Thanks. You know, I think like all of the other work that is done with serious or chronically ill people, attention to anticipatory guidance is really important. If your plan or your benefit has a time limit like ours did, you need to make sure they understand that upfront. You also need to, you know, as time goes on, make sure that they understand that as the goals of care are being met, that the person may be moving away from the need for a heavy touch kind of program or what have you. The other thing is I really think you need to pay close attention to a very solid care plan that everybody understands and can implement because that's the care plan you're going to hand back to whoever then assumes primary care for that patient. There needs to be processes where that transition, that handoff is done smoothly and in a predictable way that minimizes crisis and chaos and drama. And then I think, you know, you could think about interval check-ins, especially for those that, you know, at some point are going to find themselves with their disease progressing and will need more care. And maybe that's quarterly or every six months or something like that. But, you know, that might be helpful for that transition. Thank you so much for sharing that, Ray. So pragmatic, too. Allison, this question may be for you, but there was someone that sent me a note asking about new Medicare Advantage supplemental offerings or benefits or however you want to frame it up for patients with very complex and serious illness. And I was wondering, Allison, if you wouldn't just mind sharing just a little technical perspective on what's happening in Medicare Advantage and also any resources we could send to people about that. Allison? I think she actually had to drop off and said she was going to rejoin on her phone. Oh, okay. All right. Well, we'll shift away from that topic. Maybe we'll bring that one back in a minute. Does anyone else? Go ahead. While we're waiting on Allison to get back, I just had one follow-on to Ray's comment, which is that I also think this is another topic where you really anticipate it in the training of your staff and in the verbal, you know, the language you give them for setting expectations, because I think the staff becomes codependent with the family and thinks nobody can take as good a care of them as them. And if you start off saying with indefinite, we'll come see you every whatever, then it's a takeaway. But you can always set a limited expectation. We're going to come see you at least a couple of times to do the following. You can always extend it, but taking away is hard. So just thinking through how you set your staff up to set limits and make it a positive when you extend versus a negative when you start extracting yourself could be helpful for them. Excellent. We're going to transition to a summary, and then we're going to be moving to the post-formal session breakouts if people want to stay with them. Does anyone else have any questions, observations, or tips to share before we start to move into summary mode? Okay, what I'd love to do if we go to the last slide, we're just going to go around to our Faculty of Voices of Experience. We're going to ask folks to just share, you know, your reflections, your perspective, anything that you wanted to add. So Melissa, if we could just go to the last slide. Well, there it is. You know, we certainly have covered a ton today. I think we've gotten into some granular detail, also some strategic, but here are just some key takeaways around each of the sections for you to kind of go back and hang up on your wall to remind yourself, maybe put it up as a placard, but certainly wanted to try to hit that element from that payment all the way through these operational questions. And we'd just love to step back for a minute and ask the voices of experience, you know, if you think about your one or two key lessons learned, tips, words of advice that you would want to share, would love to have you do that. And let me start with Russell, if you wouldn't mind. Sure. Well, I remember earlier you liked my phrase patient, but persistent. So there's, I know that there are for those when it's kind of hard to move, for those when it's kind of hard to move the ball a little bit. I, again, think the idea of offering time limited or pilot programs. I love what you said earlier about helping to figure out what the problem is that they're trying to solve. So that's something I'm actively engaged in right now and saying, is there a problem to be solved? And do you, how do you perceive that? I'm working with a group that really has a hard time with this idea of community-based palliative care because they have such a strong presence in a large geographical area in a clinic setting. And they're, they're wondering both about the value add, and then also very concerned about competition. So I've asked them to give us, and they have just a couple of patients that we could sort of co-manage where those patients who have been seen in the clinic could also be seen in the home setting kind of as our team seen as extenders, extenders in an effort to show how we can collaborate with those, with the team, the care team in the clinic setting and how we can be the eyes and the ears beyond those walls. One theme obviously is that, that this all does take time. I think one slide we had when we did the session in the past, like whatever time you think it's going to take, what does it double it or triple it or something? So it does take time. And I think your point about competition certainly is a fear that some people might have in different ways. And I don't know how you position it, but I think of this, I think there's more than enough volume to go around. There's a lot of need out there and you're trying to work with a very small volume of patients that have a big impact. And so language around that, I'm sure you can run into that in different ways. Right. And also talking about the continuum versus the competition, the clinic setting is obviously very different from the home setting. Yep. Yep. Thank you. Rebecca, would you share your tips, words of advice, perspective for folks? Well, I think one of the things that we didn't really have a lot of discussion about was quality metrics. And I do, you know, being a clinician myself and a lot of the people on the call are clinicians, I do think that we need to balance all of these costs and utilization metrics with quality metrics that are really meaningful for our patients. And, you know, sometimes it's the, you know, reducing cost and hospital utilization that gets you in the door with the payer. But most of them also really care about the quality outcomes because they're having those reported to CMS and other places. So I just, you know, I don't have any, I mean, it would take, you know, I have ideas and have certainly experience in a number of our contracts and building the right quality metrics. But, you know, most of us know that the typical HEDIS measures are not the ones that are really that, always that meaningful for our population. So looking at, you know, palliative care metrics, and of course, people like Bruce Luff and Christine Ritchie have written a lot about appropriate home-based primary care quality metrics. And CAHPSI has a lot of information on palliative measures, but I just, I think all, an ideal contract has both, you know, it has a quality bonus structure to it or a gateway, and then it has a shared savings component based on total cost of care. And I think some of the words of wisdom and guidance we heard today too was, you know, not attaching yourself too much to metrics that you can't directly influence, right? And so how do you, you know, put some thresholds or ranges or acknowledge that it's there, but to your point is it's not just cost, but quality as well. And I think you even extended it to thinking about, I remember a couple of years ago, we worked with health plans and one of them was talking about their palliative care benefit to employers, talking about the value to their employees around all the caregiver costs it was taking them to take care of these people. And if you can have good effective supports, it actually helped affect some of the caregiver angles well too. So I think there's a lot of ways to your point about the quality pieces to weave in there, but that's great, great perspective. Leanna would love to get your closing insights and brilliant words of wisdom for us. I would just like to share, I think it's really exciting to learn about all of the different ways and iterations of work that's taking place and yet still so impactful and making a benefit to the community and the footprints that you're touching. I know in our breakout, I think it was Bridget who shared, you know, she always feels like she's in a constant state of a PDSA cycle, but I think that's exactly where people should be. And that's because the work continues to evolve. And as Lynn was, you know, sharing some tools that are tangible that you can take a snapshot and see how you're doing. Again, we talked about that's an ongoing, you know, basis that needs to be done. And I do think it's important though, that there's some buy-in that's created with either the internal company that is assisting you with your work or that you're working with or the payers and having conversation about the type of work that's being conducted will continue to evolve. And sometimes that happens quickly. So last year you may have been executing work in a certain manner, but next year you might have enhancements, but there will be additional asks or additional outcomes associated with that to back it up. But I think it's critical to have that conversation that this is a very quickly evolving type of work and population and how you go about addressing that will continue to evolve with it. Wonderful. Thank you. And that whole point of that it's an evolutionary process, staging it in waves, et cetera, and planning for that. Thank you. Laura, your words of wisdom and guidance, reflection. So much good words of wisdom already shared. And I echo a lot of that. I think for me, my approach has always been to really try to focus on the relationships and keep those going, get your foot in the door in whatever way you can. So I may want to have a fully fleshed out palliative care program that has a per member per month with this payer or with this ACO, and I'm not going to get that tomorrow. But I might get an opportunity to speak with the ACO practices about what we're doing, let them get to know me and make sure they know what we're doing and then build on that relationship and build that trust so that then we can potentially go into that value-based model. And our community is fortunately has a lot of clinicians in this area who tend to stay here and a lot of people know each other. So that is helpful to kind of build on that longevity, but then also to find champions within the areas that you're working in. So I could talk about this till I'm blue in the face and obviously I'm passionate about it. It's really helpful to find those champions within the payer system, within the practices. We found champions within the advanced heart failure teams and they helped us get grants so that we could support programs that help support their patients. And so really getting those external and internal champions can be very helpful. And using just real patient stories to help illustrate what we're trying to do, because ultimately that's what it's about. And I think I've talked with so many different people at the payer level and the C-suite level. And at the end of the day, they are also all humans who have family members who are sick sometimes and who have used different services or have needed something. And so I think connecting at that personal level can really get the point to resonate. I think your point about relationships is so critical and your point about champions, like having others carry the water kind of concept of someone else's voice is stronger than yours sometimes. And so back to our points early on about having a really good service expectations, access and having others speak highly of what you're doing can be very powerful. Thank you. Lynn, your perspective? Well, been great discussions. I'd had a couple of things to comment on and actually Laura said something that gave me an opening, which is when you think about getting a grant, we tend to think, oh, that's soft money and we're trying to show that we're cost effective and we're going to pay for this thing on kind of hard green dollars. But if you instead kind of go to the structure of the business tools where there's a startup period and then there's sustainability, there's a lot of justification for strategically seeking partners and grant money to start something out, to pilot something, to do something that's different. Business as usual doesn't get us here. Healthcare as usual does not get the change we're going for. And so whether it's coming from an employer, a payer, a health system, or a private individual, getting some grant money strategically put in to help you get the startup going is a good strategy and actually can create another voice and advocate. And other people can get money that you may not be able to get. So I really think it should be part of your strategy and not viewed as a sign of we couldn't get paid for what we're doing. Seek it out. Don't do it as your only solution because in the long run, that will not work well. The other thing, and I think Russell, I believe you said this, but the idea that we're not really competitors. I almost laugh when I see like a good health system program that's inpatient and maybe in a clinic. And then they're thinking, well, we don't want to partner with so-and-so and have them provide our home-based model. And I'm going, why the heck not? You need scale. You'd rather have one good organization that four competitors work with and have it have the scale to provide reliable services at home than to have three little programs that can't put forward enough people with enough reliability to do it right. So I do believe this is an area, again, where we've got a gap. We're not competitors in most of this stuff. We're trying to provide the best care to the right patients in the right way. And collaborating across normal competitors can be a very good way of doing this. So I don't think we have to, to me, home-based palliative care, home-based care in general is not an area where we need to fight over it. We need to figure out efficiency and effectiveness. So I'm particularly interested in that because I think reliability is very important and that requires some scale in a lot of communities, maybe not LA, but a lot of communities are simply not big enough to appropriately justify it, to have a bunch of different little players. So that's my two bits. That's great, Lynn. Thank you. I just, is Alison, I know Alison had, was sorting out her technology side of it. Alison, are you able to hear us? Are you on? Okay. So my only last words of wisdom is, is everything I, everyone said, but don't get in over your skis or over your head or under promise, over deliver, whatever it is, is that you really do want to be thoughtful about your plan, stage it forward and not getting out ahead of where you actually have resources to do it well, because you want to go out of the gate strong. So getting that minimum critical mass of staffing to do it well is certainly a lesson we've all seen. So this, actually, we've done a great discussion. We are actually at the final moment here. We have finished all of our content. We have made available to you, if folks would like to stay on, you can actually, we're going to have four breakout rooms and you're going to be able to select who you'd like to go talk with. We've got folks in pairs. And so we're going to have Russell and Rebecca in one room, Leanna and Laura in another, Lynn will be in a room of her own, and then Alison and I will be in the main base. And I'm going to let Melissa describe what we need to do, but I just wanted to pause for a moment and say, first of all, thank you to Laura and Russell and Rebecca and Leanna and Lynn for all of your generous contributions today. You shared tons of your background and perspectives and experiences and practical lessons learned. So thank you so much. Alison, if she were on here too, would be saying the same thing, I'm sure. And then the HCCI team has been absolutely phenomenal in helping work with CAPC to get all the pieces done together. So this partnership has been wonderful today. And so I just wanted to make sure I sent out my thanks to everybody. There's a lot of materials that you can get access to the ideas to go and get it and use it. And I'm going to turn it over to Melissa to help us talk through the breakout groups now. But if you need to leave and hop off, you're welcome to do that. But if you want to stay, please do so. And thank you all so much. Yeah. Thanks so much, Tom. And I just want to echo the thanks and praise that you heaped on our faculty, our voices of experience. Thank you all. It was really fantastic to collaborate with CAPC on this event today. And

Home-Centered Care Institute

Center to Advance Palliative Care

universal access

high-quality home-based care

value-based payment models

strategic relationships

partnerships

organization

costs

patient engagement

stratification

active listening

shared decision-making

goal-setting

adaptive strategies