A Value-Based Merger

Speaker A: Welcome to the Disruptive Podcast. My name is Jamie and we're, uh, here with another episode and Scott is currently in Chicago, Illinois right now. Scott, how are you doing there?

Speaker B: Yeah, doing good. Um, it's a little cloudy. I haven't had good travel weather lately, so, uh, you know, freezing cold when I was in Scotland and now I'm up here and it's a little on the chili, so it looks like it might rain.

Speaker A: Well, it's hot, but it's hot down here, so I mean, it's not too bad. It's actually, it's like 84 degrees here in Greenville, so it's not too bad. So that's not too bad. Have you, have you had any deep dish Chicago style pizza yet?

Speaker B: No, but I had a really good, uh, chicken parmesan last night, so that was good advice. And actually I got a little more left in the fridge, so.

Speaker A: Yeah, nice.

Speaker B: Uh, that's awesome. No, no baseball game though. So I've been looking for stuff to do, so.

Speaker A: Yeah, there you go. Well, well, Scott, um, I know we're going to jump in and we're going to talk a little bit about the merger and where you're at with that and how that's going and contracts. So let's jump into it today.

Speaker B: Yeah, so pretty exciting. So I've been, um, of course, in Atlanta the last couple of weeks, meeting with, uh, a lot of the providers and going into buildings and stuff and getting really excited about the opportunities that we have, um, with this merger with TCPA and Providence Care. I'll be in Rock Hill next week. So anybody listening? If you are in the Rock Hill area area, look for me. Um, I think they're gonna try to do some meet and greets so I can meet some of the folks. And I've kind of held off going up there only because I saw such a priority to get a good feel of what was going on, uh, over in Georgia.

Speaker A: Right.

Speaker B: And, and most of most of the. I had already met with one of the main providers, Dr. Lingos up in Rock Hill and Dr. Uh. Shaw. So I'd already kind of felt comfortable with what they were doing. And I think hospice, most of it's hospice. And, and, and so I'm not, you know, that's not something you can, quote, do wrong. Really bad. Sorry. Or good or so kind of know what's happening there because they've also been kind of our competition for a while. But I just wanted to, uh, put it out there so that everybody in both organizations will kind of know where we are. So we are still on set. Uh, you know, we have a contract. It's kind of ironclad. There's no way either group party can get out of it. It have to be something major. Um, like I'd probably have to die before this thing wouldn't go through.

Speaker A: Don't do that.

Speaker B: And even listen, even if I die, it's really not going to make that big a difference, I don't think.

Speaker A: Right.

Speaker B: Um, so it's going through. The final closing date will be July 15th. But up into that point, guys, we're, we're still. I'm basically um, responsible now for both organizations and companies and so we're trying to give direction. So what we're going to be doing, I mean, gosh, we're right on top of this thing. I mean this is the next week is July 1st and so uh, starting and it's the week of the fourth, which is going to be a lot of people on vacation taking time off. And so, um, what we've done is all the laptops are pre ordered and actually are here, I think are going to be here next week and they can be set up automatically. So as soon as we have a name on that person's laptop, we're able to give you all the login and credentials and everything you'll need based on your position. So I just found that out from Ben the other day. It's really cool. So let's just say you guys got an employee and they, they uh, they, they terminated and you've got their laptop sitting there and then you hire another person. You can actually call the ID department. You don't have to send the computers back. You just call them and remotely. They wiped that computer of everything else that was on it and then they reset it up for the new employee.

Speaker A: Wow.

Speaker B: So it happens all remotely, intensely. And I know, you know, a few months ago we were having the mail and move and, and also they've got a new system and that's gonna work out really well for us. So kind of, let me tell you what I think our priorities are as we move forward. So next week, hopefully by Tuesday, we're gonna be sending out emailing out contracts, um, to all of our TCPA and Providence care providers. And the reason we're doing this is that the intent is that we will not be using the TCPA or Providence Care physician numbers after July 15th. Everybody will be moving into um, our Thena network, but it will also be under our current, your health provider number. It will make it a whole Lot easier. Just as I like to explain to folks, look, we bill 650 various codes in a given year, TCPA, uh, and build billing 40. So we were leaving a lot of dollars up front, dollars on the table. We were also just not capturing a lot of things at TCPA level. So what this is going to allow us to do is. And then all, of course the data from these providers will then now start feeding into our power BI reports. Right. So we want to get people switched over. Now will everybody switch be switched over on July 15th using Athena or. Absolutely not. Now here's a cool thing though, is that this week they're actually going to roll out Clenny. So for everybody to understand, Clenny is a separate program that tracks all of our care management. Right. For one thing, it does a lot of other stuff. Yep. Um, and it, it will, um, that's where you start capturing that. It is an app. You can actually download the app. I did it the other day on my phone and I don't even have access to Clini. But you know why I did it? Because I can use my remote patient monitoring equipment. It comes from Clenny as well. So my, um, I could, I lost a little phone they gave me, uh, in my travel. It's probably stuck in the bottom of a car somewhere. But that little phone they gave me was gone. And so I went in to talk to the guys and they said, oh, you can use your phone. And so I downloaded the Klenie app and it automatically connected up to my, uh, my equipment. And now I can use that instead of having to carry a separate entity for remote patient monitoring.

Speaker A: Wow.

Speaker B: Isn't that cool?

Speaker A: That's awesome.

Speaker B: Yeah. So, um, so Clini does a lot. Clenny is also going to be. Our new phone system that's getting ready to roll out is so fabulous. Um, what you'll be able to do is call in and say, hey, you know, my name is Scott Middleton. It identifies who we are. I need to speak to my nurse. I just say speak to my nurse. It's going to route me because I'm a Main street physician's, uh, um, patient. It will need to mainstream and it will take me there. Um, it will be able to answer and respond and talk because it's AI just like anybody else. It's, it's going to be a great thing. The other thing, uh, the Clini is doing for us now is that we're going to be able to offer a wristband with a QR code on it. Mhm. That we can give to our patients. And if they have that on and they go to the hospital, the hospital can scan it and this hospital will see their medical records coming from Athena. Wow. That's uh, including advanced care plans, uh, power of attorneys and all of that information that um, do not resuscitate that need to be seen.

Speaker A: Yeah, that's, that's super powerful. Now is this what, what does the bracelet look like?

Speaker B: Um, I. Well we can put the QR code on anything and I think right now they're just looking at kind of like a rubber band bracelet. But I'm sure we can play around with that different modes.

Speaker A: That's amazing because just the time that you know, the staff, you know, when they get there, you know, especially if that person maybe, maybe they can't speak for themselves, maybe they're in assisted living. You know, there's so many reasons why that would be so helpful.

Speaker B: So yeah, the um, the bracelet, uh, we'll probably just have like one of those rubber kind of identification bracelets that you put the QR code on. But I guess we could put it on anything. You know, I could put it in my thumbs up my phone or something that, where anybody could scan it. But you know. Yeah, if you go into the emergency room right now, then they need to have records. They will actually an epic, which is most of the hospitals use, will be able to scan that and it will either um, pull that up into a document or it's something that also could be um, emailed in a fax. And so that'll have certain identifiable things that you want to make sure that they are aware of, which would include also medication list and stuff as well. So it's uh, that yeah, it's really a ah, cool product. Um, and it was pretty simple and easy to do. Now we got the idea from somebody else who tried to sell us something like that. But they wanted such an extreme amount of money. Money. We figured out that we could really do that ourselves internally. And he's done that for basically nothing. Yeah. So good. Good partner for us. Um, yeah. So um, as, as we get back to what's going on in uh, with the merger. So, so next week we'll be sending out contracts to all of our providers for our nurse practitioners and our um, and our physicians. The contracts will look a little bit different and so we also will. Is working on making sure you guys, everybody will get out the formula for actually calculate bonuses.

Speaker A: Mhm.

Speaker B: So if you go into our current power bi. Uh reports, we have an estimator for People to look well, how much would I estimate to make? And we did that based on visits and stuff so we could help explain to new providers, hey, if you do this many visits, but in the reality your pay as a provider is based on this. We look at your total amount that you have billed and what I want to emphasize is the you. Because doctors sometimes uh, we are billing like chronic care management underneath your provider number for all your staff. But I can't incentivize you on what your staff is billing out there. I can only incentivize you as to the direct care that you are providing for a patient or otherwise. I can get in trouble for all kinds of enticements and anti kickback uh, stuff. Um, I just want everybody to know you can never get a bonus as a provider because you put somebody on hospice. Um, big no, no, you have to put somebody on hospice because you feel clinically they need to be there. But I can't pay you. So that means even as a medical director, if you are referring to us, I can't base that medical director income based off of number of patients because again that encourages you to people put people on hospice that may or may not need to be. And we just don't want to emphasize that at all. So um, you're going to take what you bill and we're going to multiply that by um, your RAFT score. And so your risk adjustment factor is extremely important. Um, just to identify your RAF scores are all found in power bi. There's a lot of rumors going around that the RAFT scores are not correct and that there's an issue with fathom. There's a issue which is our coding, um, ah, software or there's an issue with Athena calculating it. Just for you guys to know all of that is untrue. Your RAFT score right now is your RAFT score. Um, it is that we moved from the V28 scoring or uh, from the V24. The RAF points. The HCC codes were reduced for a lot of diagnosis codes during that period of time. And so your RAF scores are lower. Now we do think that there is a minor ah, mess up with FATHOM related to F codes. And um, but there's only a few F codes that really have an HCC conversion factor. And so it will probably not. You probably won't even see a significant increase or change in it once we, once we do get that fixed. It's not a big factor for us. So your RAFT score is multiplied by your revenue that you are able to generate so that's why got, uh, providers. We're trying to help you generate more revenue and then you get a percentage of what that number is. So we're basically prepaying you for what we think you will bring to us, uh, as cost savings next year. Because the RAFT score impacts the amount of money and allocation we get from the ACO and from Humana credited to our patients gives us cost savings. But I'm not waiting around until we get a check. So next year, when I do get a check and you hear it, don't be thinking you're going to get more money because you've already been paid for it.

Speaker A: Right.

Speaker B: So I'm handing it to you now. And then we also have quality measures. So there's I think about 10 quality measures, including hospitalization numbers, re. Hospitalization numbers, uh, a 1Cs. I mean, I can't remember all of them, but just practical things that you as a provider should be looking at. So then you could get reduced, um, your bonus or incentive based on a negative quality measure. So for nurse practitioners, the way that works is it's roughly, uh, your income times your raft, um, and then, uh, you get 9% of that. And then it doesn't matter what your base salary is, because your base salary for all these guys, it's going to come out. So if you say, hey, I want to hire base salary, great. I don't mind giving you a higher base, but it's going to reduce your bonus. But it will be the same dollar amount of money that you would make in either capacity.

Speaker A: Yeah.

Speaker B: So we have nurse practitioners that are making 100,000. We have some that are making 160. Um, but at the end of the day it's all same when you look at your bonus structure and how it's done. So, um, the doctors for me is a little bit different. I can't remember what the percentage is, but we'll be, uh, sharing that. As far as we can see, we've gone through all of our providers, um, that are coming, um, uh, onto this new incentive. And most of them will be making more money, especially the NPs. The doctors will be about the same, um, because they also, um, we will be getting, paying them for collaboration. So currently none of them have been collaborated. So, um, next week you're going to get your contract. As soon as you sign your contract, we will, um, go ahead and start your credentialing process because we'll have to credential you under this other provider number. And once you, uh, have that, you will be able to start using Athena. So that's why our goal would be as many people as can that can start, you know, as soon after July 15th. Because technically with the merger, we really can't take income from one company and shift it to the other prior to it actually merging together. So, um, it gets conflicts with, uh, current loan agreements and other things out there. Um, so we, you know, we will, uh, we'll roll that out. Hopefully by the 15th, we will start making sure everybody gets transferred over to Athena. So the faster they learn, the better. Um, Casey Kuza has agreed to be our new vice president of education and training for Georgia.

Speaker A: Right.

Speaker B: And so she is, uh, going to start putting together a team and working with, uh, Courtney and Teresa and Becky Betsy on the ACT team again. And, uh, she's going to help us continue to oversee her region until we find somebody. But she's assured me that she has put a good team together that can really maintain what they're doing. So thank you, Casey, uh, for doing that. And, um, and then I'm sure she will be asking people from all over the state too, uh, or the both states to come in and help us. That's what she did down in Florida. You know, every week there was somebody different down there. So if you have opportunity this summer, um, and in the next few weeks that you think you can slide out and move, go over to Georgia for a week or three days or whatever to train, we sure will appreciate it. Um, so computers then will be here and ready to go. So as soon as we get your contract and credentialing, we're going to hand you your brand new computer, um, and you'll be ready to, um, start the process of switching over to Athena. And in the meantime, you'll get Clini, you already got plenty app, and you can start keeping track of your ccm. Um, for that.

Speaker A: Yeah, yeah, big shout out to the IT team getting, getting these computers all set up and, and yeah, that's amazing.

Speaker B: You know, it's something different. I was talking to Ben last week and, you know, we had had this deal with Best Buy for the longest time and then Best Buy can't get chips. And so, you know, guys, I want you to understand the issues and problems. Several people have come back and said, hey, we liked our services. How come we can't have those again? Well, there are all kinds of issues with connectivity with the services that we were having in a lot of the areas. But also, you have to understand, the surface went to 3 to $5,000. We, we were paying minimal thousand bu. 1500 for surface. We used to pay 5, $600 for a laptop and now they're $2,000 because of these chips. This stuff. When you all read in the newspaper that, you know, we're trying, all the chips are in China and we have a, uh, lack of resources of minerals to go in these things. It's a real thing. You know, that's one of the reasons they're trying to get to space fast as they can is because they think they're going to discover all these great minerals out there trying to capture an uh, asteroid and scrape, scrape the asteroid. So we got minerals to put in a computer chip. Isn't that just nuts? Yeah. So, uh, yeah, yeah. So the other will be, um, you know, just go. Everything else should kind of stay the same, uh, with the model as we start to add employees. So I've, um, I've really. We're, we're really pushing the HR department now because we've got to hire a lot of nurses. We've got got 60 providers, I guess with the, with the new company, um, coming in. And so we got 60 providers. Each of them need two nurses. We need 120 more nurses and we already need probably another hundred on our side already. So, um, a lot of, A lot of hiring and onboarding and getting people started. It's going to be the real priority.

Speaker A: Right?

Speaker B: Yeah.

Speaker A: Yeah. And I, and I think this last week you guys started doing in person orientation again. Um, I mean there's so much going on. I, I was talking to somebody, uh, to Scott about the education Department, you know, at uh, your Health. And it is just, it's, it's got so many pieces. Aubry has built just an unbelievable team of people and continuing to build that new, A uh, new internship program. And there's just so much going on right now.

Speaker B: Yeah, there it. And it's, it's all starting to move, move forward and we're starting to see a little bit of increase in our numbers. I notice our patient count was up a little bit this month and then the whole new power bi reports are rolling out now. I tell everybody when you go in now you can really drill down to your care team and see everything your care team is accomplishing. What I've been looking at with that is where are we missing the boat? For example, we've seen a decrease in our advance care plans and we're doing that. I know why. Because we've taken the um, a lot of the social workers off of the doctor teams and then m. We move them back into their care teams and they've just stopped doing ACPs and nobody else is picking up on top of that. That's going to greatly impact our um, hospice census, our palliative census. Um, and I think it increases our hospitalization. So right now we're sitting at about 10% ACPS. We've been running 13. We should be at minimum of 15. But I really 18 to 20 is kind of my number. Um, so. But it very, you can see it so much easier and now you know exactly where you're missing. So before you could look as a region, where am I at? But now you can go down to the actual care team and say this is what we need to emphasize.

Speaker A: Right.

Speaker B: Um, you know, your number of visits and all of that. That's in power bi. So guys that are coming on board with us, we're going to be able to track so many more things for you and you're going to really be able to say, hey, where should I emphasize? Um, as I talked last week, one of the biggest factors that we really want to look at, um, with the TCP group in Georgia in particular, because they do a lot of skilled nursing facilities, uh, we are through that organization and I'm using the we term because it's all we now. So we as former TCPA, um, we have been discharging about 460 patients a month and we've been discharging them when they leave the skilled. So what I want people to understand is that under our value based contracts, which are Humana Blue Cross, um, there's a couple of smaller MA plans and of course traditional Medicare. Under those plans, guys, whoever sees the patient the most gets attributed to that patient. And a lot of folks think, oh yeah, but every year they roll off. It doesn't start over at the beginning of the year. If I was wearing a nursing home three years ago and I saw you 12 times in the nursing home and I have not been to any one provider more than 12 times, I'm still

Speaker A: attributed to uh, and explain to people what that really means. That means you're paying the bill.

Speaker B: Right. So that means that that patient is attributed to our provider number and at the end of the year, all of that patient's claims data is into the system and we it will be counted pro and con with us. So here's a great example. All these patients that we have put on hospice and then the hospice discharges them from our services, they that but they are still aligned to us. Right?

Speaker A: Right.

Speaker B: So what most hospices are doing is the patient never sees a provider again for a billable visit. Which means that the risk scores aren't being calculated.

Speaker A: Yeah. Which they should be.

Speaker B: Right. So that means January 1st, all of that drops. And that means that that person now only has their, uh, demographics of 0.3, 0.5 down there. That means they're only going to get attributed a few thousand dollars. And yet we're spending $6,000 a month, you know, $60,000 a plus and over, over in a year. And we don't have any credit for it. So as I was explaining to some folks the other day, we were pulling just Agape Cares patients because they have the most hospice patients, uh, from your health. And just with the existing patients, we don't even know how many former patients there are. It will cost us about $20 million this year in money that should have been paid back to us as incentives and bonuses. So when somebody goes out there, well, y' all being mean to Agape guys. Agape being mean to us. And they didn't mean to. I'm not pointing fingers like they're bad people or anything. It's just their average length of stay for our patients is well over 200 and something days. And guys, we're oftentimes the ones signing those research. And we have to. Well, hopefully not signing the research. Hopefully they're doing their own. But, um, yeah, so they're signing research on patients to put, to keep them on over and over and over again. That's why we started hospice. If anybody ever wants to know, you can point them to this podcast. Because our hospices were, uh, not. They're costing us a lot of money. And then what will happen with some of them? I haven't seen that with Agape Care in particular, but some of the other, uh, groups, they will hold patients, and you'll notice that after 12 months, they just start discharging left and right. And I actually talked to a hospice group a while back and they said, yeah, once somebody's been on hospice 12 months, we look at it and I'm going, what? You should be looking at it every certification period.

Speaker A: Right.

Speaker B: And scrutinizing. Does this person really, you know, do you still think they're six months or less to live?

Speaker A: Right.

Speaker B: Or have they gotten better?

Speaker A: You know, the whole point of the, you know. You know, that's the whole point of it.

Speaker B: Right, exactly. Exactly. Um, so, uh, the, the other thing I'll say that we're emphasizing, and I think we're going to actually see TCPA and Providence Care. They see Their patients a lot. They see them more than we do. Guys. I'll just tell you that, um, the al patients may be not quite as much because they don't have facilitators, but in the nursing home they are seeing these patients every opportunity, um, you know, which I love. So there's a skill building out here. 63 beds, 65 beds maybe, um, all short term, meaning they're less. They came right out of the hospital, left there, um, in 20 days. So really those patients should and could be seen every single day, um, while they're in that um, skilled facility. Because a lot of things could happen while they're in active rehab and all. So you really think they got 60 patients time times 30 days. So they could be doing 100 and um, 80 or 1800 visits in a month and they may be close to that. You know, they probably because they have three providers are probably about 14, 1500. So good numbers for them to do. But again, all those patients are attributed to us probably the rest of their lives because nobody else is going to see them that much.

Speaker A: Yeah, yeah. Because I mean a normal provider, they're not, they're just not going to, they don't, they don't operate like that.

Speaker B: No. Most of them will see people quarterly. So how long is it going to take them to uh, to see a patient? 20 times.

Speaker A: Right.

Speaker B: You know, five years.

Speaker A: Yeah, exactly. Yeah, yeah. It's ah, it's that's just the way the normal, you know, healthcare system works, unfortunately.

Speaker B: Yeah. So, um, the excite, the now I will. The other, the other piece I think of all this is then as we start hiring more of the nurs, we have the opportunity to start using our specialty division. And what's kind of been intriguing as I've walked in these nursing homes, they have signed contracts with companies everywhere, um, to do things for them. So like one of the nursing homes has a contract I think with Insight or on site. So on site is a, um, program, um, designed around capturing transitional care visits. And it's all online. We have hospitals and nursing homes that are actually paying for on site to do that. Well guys, that's something we do as well. So as soon as you go home again, the telehealth visits can go from those providers. And it would be much better for our providers who've been seeing this patient for the last 30 days to follow them versus some um, stranger in New Mexico who happens to be working part time for on site. And they are just getting um, a fee for service. Um, so uh, we've got to pick those visits up. I was talking to a provider the other day and he's got excess time, um, and he could probably pick up another two to 300 visits a month just by following along patients that have discharged. So pretty exciting, um, opportunities out there, uh, for everybody.

Speaker A: Yeah. Scott, what do you think as you're meeting with new people and kind of. Because there's always going to be things where people are confused. What's the biggest thing you hear that people might be confused about or maybe have a, um, maybe they just, they don't fully understand, you know. You know, as they've come over, uh, to the, your health organization.

Speaker B: Um, yeah. So there was a lot of confusion about care management. And so let me spend just a minute about this. So, um, care management, I want to give the definition. Care management is designed to provide a payment to help offset the time that providers and staff spend to gather information and to disseminate information for patients to be compliant to their orders.

Speaker A: Mhm.

Speaker B: So here's an example. I need to go through these notes. I need to talk to the family. I need to spend 30 minutes with the patient. None of that is included in a CPT code. Billing for medical complexity. But right now a lot of the providers are putting time on their um, uh, within their uh, documentation. If you ever put time, if you list the number of minutes or start and stop time, the coding, the coders will automatically code it based on time. And we don't do that. We base on medical decision. The gathering of all that information should be, is not included in that CPT code payment for medical, uh, complexity. So making sure you're capturing that under your care management. So that's what you'll log in. Clenny. I walk into somebody's room or either I'm sitting outside the room and I'm reading through some notes before I go in to see the patient. As soon as I open that chart, I'm clicking the timer on Clini or I'm counting those minutes up until the time that I finish that chart. All of that would be included in care management. So our providers, if you spent 20, 30 minutes with them, that almost all of that should, or all of it should be considered part of care management. Then you will bill your medical decision making. So also, um, at the same time think about you're going to be reimbursed based on how much you bill. And the reason we do that is because we've discovered the more visits we have with a patient, the less likely they are to go. The Hospital. So Will actually just finished pulling numbers. He sent out a report to some folks the other day. Was a wee bit confusing, Will on a couple of things, but I'll try to clarify that. But what he was showing is that, and his explanation was that with those folks that are, say, between a, uh, one and a half and a three and a half on the risk score, that capturing 300 minutes of CCM a month put us into a window of better cost savings with those patients.

Speaker A: Yeah.

Speaker B: So having, having those touches, but with any patient that was above a 3, the significance to red reduction wasn't an increase in CCM that we didn't see going from 300 minutes to 600 minutes was, was making a significant difference. But the significant difference was in the visits.

Speaker A: Right.

Speaker B: So the more visits you did with that higher acuity patient, then we saw a reduction. Now, the more visits you do, of course, the more CCM you're going. But if you do CCM on those patients without doing visits, you're not going to see a significant drop in hospitalizations visits. So that's where we're trying to help, um, the TCPA group, uh, out there. So we don't skew our data either because they've been using CCM as I couldn't do a visit, but I talked to the patient. They may have had the conversation with the patient or the staff at the facility giving them orders, change this, go run this, or get me an X ray. And they're not billing for a visit. So guys, we have to bill for the services we provide because otherwise we don't have the data to know whether our stuff is working. Um, so bill for the visit. So what they're going to be able to do now is start picking up more of those telehealths, um, and they haven't been. When they walk into a room right now and spend an hour with the patient, they haven't been logged in CCM for that. So great opportunity for them, um, to pick up their belly then acp. These advance care plans, remember, advanced care plan is conversation to make sure that people are ready for what's going to happen to them when they are there in their last few months of life. And you should be doing those regularly. Every provider should have documented on an advance care plan for themselves. Um, so I don't care if the NP did one yesterday, the doctor can do one today, the specialist can do one. Because if you are not aware of that person's wishes and have a full understanding and your team has not had that conversation, we'll make bad decisions.

Speaker A: Right.

Speaker B: So go ahead and do the advanced care plan. It's also a huge compensation piece of it. So guys, that adds another 80 something dollars to a claim. So we're going to take providers out there who've been billing 80 bucks. Oh, also we weren't billing um, under there, the G code modifiers, um, for the care coordination. So we're going to take people who've been, they've been collecting on average of about $80 a visit and now blended with doing your advanced care plans at 15 to 20% of your visits, you should actually be able to get an average charge of visits well in excess of $100 and probably $30. So we can increase their billable income by 30%.

Speaker A: Wow, that's huge.

Speaker B: Yeah.

Speaker A: Uh, do Scott, do you feel like everybody that you know, the people that have just come on board, do you feel like they have a grass grasp of all the different positions that are available as far as like resources, you know, having, you know, a nurse, you know, a nurse that's going to go out and actually see patients, a case manager, you know, um, do you feel like they understand the structure of the team?

Speaker B: I don't think our, I don't think everybody in our company, that some people have been working here five years, they don't understand it. So I, I think that's, that's right. And to know that the teams have to be flexible. I'm glad you brought that up because here's an example. I walked into a nursing home the other day. So our care teams, a care team is made up by nurse practitioner in the field. Right. That nurse practitioner has two nurses, two community health workers. They have an ma, they have a care manager who is coordinating the entire schedule for all of the uh, of the care team. Right, Right. So it's not just scheduling patients, it's making sure that the care team is scheduled. So you have uh, individual, you have. So I think I said social services, um, as well. So you have an ma, a care manager and a social services specialist. So at minimum you have 2, 4, 6, 8 people on your care team.

Speaker A: Yeah.

Speaker B: But you also have PTA and coda.

Speaker A: Mhm.

Speaker B: That's on the care team. Well, in these skilled facilities, I'm going to walk into a Pruitt Health that has their own therapist in there, there. And their own hospice. Right, Right. You're not going to have a PTA and a coda, and you're not going to have any extra hospice nurses. So what we've done is for the care team now is we've gone back and said every care team now, in addition to their two nurses, can go ahead and hire a. I, uh, can't believe I'm saying this. A nurse who's predominantly going to do hospice. So a person who knows hospice.

Speaker A: Right.

Speaker B: Because what's happening is our teams are saying, hey, I don't know hospice, so I'm not therefore not going to do, do it. So hire you a hospice nurse. Now, over time, all the nurses will have to document in the hospice charts if they're going to see a patient.

Speaker A: Right?

Speaker B: But right now, some of them just need somebody who does it. So every team, Every team in our company. But now, unless you're in a Pruitt building, you can't have, um, our hospice. Right? So you won't have a hospice nurse.

Speaker A: Right?

Speaker B: So, guys, you have to start thinking clearly what you need. But now most home teams are going to have three nurses then, because for every hospice patient, they're also going to have, um, another nursing assistant or hospice aide, Community health worker is what we call them. But they're going to have a hospice aide for every four patients. So if they have four people or eight, 10 people on hospice is what we would hope. Because we hope this, the hospice census will be about a 1 to 20 ratio for you to add that nurse. But you don't have to wait till 20, you know, patients. I mean, if you have five patients, go ahead and hire the nurse because you're not upheld. Uh, if you have one patient, hire the nurse because, you know, you got more hospice patients. You're just not gonna, you can't, can't have people on hospice if you don't have a nurse. So you have to hire in advance. So if you, if you do that, you've got a lot of staff, but you may not need the PTA or coda, or you may need them, or you may not need the hospice, uh, nurse and the extra hospice Aiden out there. So think clearly about where those positions are. Now, here's the other side. Once you get all those positions, you are accountable to make sure they're productive. And how are we judging productivity? It's based on facilitated visits. Remember that if you are facilitating the visit. Guys, there were some questions about this. People thought, well, if the provider is in the building, that's not a facilitated visit. Yes, it is. So, example, I walked into a nursing home the other day. It's owned by Emory Hospital System, and it's a, it's called Grady, but Grady is part of that system. So uh, 300 beds of nursing there and I bed and we have the nurse practitioners are the only thing we have in the building. So I told them immediately to start hiring nurses. So I said here's what can happen. You can have a nurse and a nurse practitioner. The nurse can go down one hall doing follow ups. Here's all the patients that she saw, you know, the last two or three days that I need to do a follow up on. Um, she can update the chart and the medical record and then she can either call the provider who could be on the side of the building and do a telehealth, or the other provider, the provider can wait toward the end of the day and just walk around and lay eyes on all the patients, review the documentation, sign off on the visit. That's a facilitated visit. Even though the provider may have actually seen the person in person. You're still going to bill it as an in person visit. But we're also going to log it in Clenney as a facilitated visit and compensate the provider daughter or the nurse. If the nurse or the community health worker is doing the documentation, then they get credit for the visit as a facilitated visit. So you could have an in person visit actually be occurred as a facilitator if they happen to be in the same building. But we are going to pay you for that facilitated visit too. And I think a lot of people aren't doing that right now. So people aren't getting their full bonus. But I won't give them credit for what they're doing. So I'm watching to see if you're productive. And guys, uh, my expectation is that if you're working full time, you better have 150 hours of care management. Because I want to look at, well what are you, if you're not working with a patient, what are you doing? And so you can have non billable care management that you're doing for commercial patients, employees and all that. You got to log that too. Um, and I'm looking at advanced care plans pretty heavy. If you are not doing advanced care plans at all, you need to learn how to do it. I don't care what position you are, you have to as an employee with our organization, you have to feel comfortable having that death and dying question, uh, conversations with our patients.

Speaker A: Mhm.

Speaker B: And so get on the phone with Donnie. If you need to learn training, go online to some of our training modules. Go uh, look at the hundred questions you can use to stimulate an advanced care plan. And the reason we're doing this, guys, is hospitalization. We're trying to reduce those. And there's a direct correlation with doing those visit those advanced care plans and reducing the hospitalizations.

Speaker A: Right? Yeah. That's great. So much to learn for everybody, you know, and I. And it, it will come together. And again, um, it's going to make things so much better. You're gonna, you know, it's gonna be so much more reach, uh, for your health.

Speaker B: It really will. Yeah. I'm very excited. It's, um, um, we're. And it's going to give us the model that we have to go other places, you know, and uh, the relationships. Now, um, I will say this couple of things about skilled nursing. So we are, um. I was talking with the Grand Strand team the other day and they got so excited after coming to Georgia and um, seeing all the nursing homes. And they came back and said, we're going to go get all the nursing homes in the Grand Strand. We want them to work, you know, be on our services. And I said, go. Great. And um, and so they were talking about what their marketing model is. And I said, well, who's your doctor? Who's your medical director? M. And they. It was kind of quiet and I said, no. I said, who are you going to use? I said, here's the way it works. If you're going to market to a skilled nursing facility, they have a lot of regulation, lots of. I mean, it's. Nursing home is still the most heavily regulated industry in the country. It has more regulations than the nuclear power groups. I mean, it's. It's crazy. You cannot just walk in. Your doctors need to be hopefully certified as a medical director because most, most skilled facilities are going to say, I'm not touching you. If you're not a certified medical director, you have to know how to do qapi. You have to know the regulations and stay within those regulations. So I encourage Grand Strand to go out there and find a doctor that has that qualification and then include them as part of their care groups and using that doctor. So, like, we're looking at a new building in um, in Georgia next week and the appointment on Monday is with the doctor. We're not even sending in the marketing team, the product team. They're not going to even be there. The doctor is going to talk about what they want to talk about now. He's going to mention that, you know, we have opportunities for staffing and that kind of thing. And our marketing department will come in or, uh, development people come in and share that information with them. Um, assisted Living. Same way you got to know who the provider is going to be and walk them in the door before they're going to say yes or no. Right to you. Unless they're just desperate. Yeah, but people want to know. The providers can be.

Speaker A: Mhm. Yeah. Yeah. I mean, who doesn't want to know that?

Speaker B: Yeah, absolutely.

Speaker A: Yeah. And, uh, that's, that's amazing. Scott, this is great. Thanks, um, so much for this. Uh, you know, we've said this multiple times on multiple podcasts, but welcome, you know, for, if you're listening to this for the first time, this podcast, there's so much you can learn on here, so many things that Scott goes over and, uh, it's a great place to know what's going on on a weekly basis. So, Scott, thanks so much.

Speaker B: And what, And I will say this, Jamie, thanks for, for those guys that are listening. Um, I know I probably overwhelm you. By the time you get off, you go, oh, God, there's no way I'm going to know all of this. That's why. Um, but I want you to understand the basics and the overview. And as people are coming on board and being trained, it's all going to make sense. You're going to go because otherwise you're going to be going, well, why do I have to do this? You know, people used to say, why do I have to log in, cleaning what I've done? You know, it doesn't matter. Or I did it and the patient had a good impact. Well, now you understand why. So, so go. I just try to give everybody the why first and then we'll show you the how. But I, uh, think it'll all come together as we start rolling out, um, the education and training over the next couple of weeks. Yeah, great. All right, well, Jamie, you have a great weekend. Everybody out there, have a good one and we'll see you Monday.

Speaker A: Thanks.

Speaker B: All right, bye.

Speaker A: Bye.

Speaker B: Thanks.

Speaker A: Bye. Scott said in this episode, I want to give everybody the why first and then we'll show you the how. And if you listened all the way through, you felt the difference that makes, because nothing we talked about today, the contracts, the RAFT scores, the attribution, the wristbands, none of it makes sense as a list of tasks. It only makes sense when you understand most what it's for. We're not logging a visit to check a box. We're following a patient because somebody has to. And most of the system has decided not to. And that's a shame. So here's my challenge for you this week. Wherever you sit, find the one thing you've been doing without knowing why. The form, the call, the follow up, and go ask the question. Because the people who change the broken systems usually aren't the ones with the best answers. They're the ones willing to ask the better question. Thanks so much for listening to the Disruptive podcast. We'll catch you next time. Go have a great weekend.