2022 Annual Meeting Session Descriptions


Friday, Oct. 27 (Day 1)

Caring for people living with dementia and their caregivers in home-based primary care (CP, ED)
Dementia prevalence among homebound older adults receiving home-based primary care (HBPC) is high. Caring for people living with dementia (PLWD) and their caregivers is challenging. Evidence-based interventions for homebound PLWD have been tested in ambulatory practice but not in HBPC. This session will: 1) describe the characteristics of homebound older adults with dementia; 2) describe evidence-based approaches to caring for PLWD; 3) expert panel discussion on how to apply learnings from ambulatory-based models to HBPC.


AI-Driven Remote Patient Management to improve Rural Access to Care (PH/EQ)
In spite of the many advances, there are still strong headwinds causing health disparities for rural communities. 81% of rural US is considered medically underserved. Improving infrastructure, wearable biosensors, and AI-driven software can reduce cost of care and expand access like never before.


Diagnosis of Urinary Tract Infection in Homebound Older Adults (CP)
Older adults are frequently prescribed antibiotics for suspected urinary tract infections (UTI). While this is a common infection, overdiagnosis and overtreatment are nonetheless common, with significant consequences including antibiotic resistance, medication-related adverse events, increased drug interactions, and increased costs. We will review the available literature on UTI diagnosis and treatment in older adults and present a newly developed nurse-led algorithm to guide the diagnosis and initial management of UTIs among homebound older adults, balancing prompt initial treatment when warranted with appropriate antibiotic stewardship.


"I can't hear you!": Geriatric Virtual In-Home Care (CP, ED, HP, PH/EQ, PM, VA)
30 min presentation of best practices and lessons learned for Home Based Primary Care in urban and rural settings. This presentation will highlight a successful virtual implementation experience (Austin, TX) and best practices, and a program that had other unique challenges (Battle Creek, MI). This presentation will explore pros and cons of virtual modalities for work that was traditionally provided face-to-face pre-pandemic. Will review Emergency Authorization allowing increased access to patient care and other procedural changes.


Dying at Home: Certification (CP)
Dying at home is becoming more common as more patients elect hospice care at end of life. As home care providers, we should have comfort with explaining not just the medical process of death, but also the practical aspects of what families/caregivers may go through. One particular part of this process is death certification, which is often required of PCPs, and through our talk, we aim to help providers navigate the medical certification form to ensure its timely and appropriate completion.


ACO Reach Model
This presentation will focus on the ACO Reach model, diving into the key model design elements, opportunities and challenges that exist for Home Based Primary Care Providers. Speakers will discuss their experiences with the model, both from a provider perspective and an enablement provider support perspective and the key lessons they have learned.


Urgent Dispatch and Community Paramedicine: Meeting Patients Where They Are (CP. PH/EQ)
Care at home is becoming more and more appealing to patients, even those who previously did not qualify for traditional home-based services. The Cleveland Clinic has developed an agile, on-demand approach to providing home-based urgent care services for any patient in need.

Rethinking Community-Based Palliative Care (PH/EQ)
This presentation will discuss a variety of models of palliative care delivery used in various environments. We will discuss how these models are staffed and reimbursed, how they integrate with other home-based medical programs, and how analytics can be utilized to best stratify patient selection and optimize plans of care.


The Emerging Clinical Model for Home-Centered Cancer Care - (CP, HaH)
The traditional path of cancer care today includes therapies provided at infusion centers, combined with supportive therapies provided at a clinic, hospital or emergency department. Attendees of this session will learn about a new patient-centric approach that brings cancer care into the home. Leveraging integrated virtual care and remote patient monitoring as well as in-person home care medicine, the model can provide safe, effective cancer care that offers more comfort and satisfaction for patients and their loved ones. A physician leader from the University of Colorado's UCHealth will describe how the model is being applied to manage bone marrow transplant patients at home. Clinicians will learn how patients are identified for home-centered cancer care, the logistics and responsibilities of each clinical role, and methods for predicting patient needs and providing appropriate interventions.


Caring for the LGBTQ+ older adult at home (CP, PH/EQ)
Being unpartnered, living in poverty, and experiencing social isolation are all risk factors for being homebound. As such, it could be surmised that LGBTQ+ older adults are at higher risk for being homebound. Having strangers enter the home, even clinicians, might be traumatizing for LGBTQ older adults who have historically been discriminated against in healthcare. We must educate the homecare workforce around key aspects in caring for LGBTQ+ older adults to ensure we are providing equitable and affirming care. This session will begin a discussion of how to better provide support and medical care for homebound LGBTQ older adults.


Strategies for Keeping Your Interprofessional HCM Team Up to Date on Evidence Based Care (PM/ED)
Home Care Medicine(HCM) teams are providing complex care to patients who are vulnerable and homebound. Medicine is rapidly evolving and we need to ensure that our teams are up to date on the latest practice guidelines. Given the strength of our care comes from our interprofessional teams, we have the unique opportunity to continue to learn together and from each other. This can be challenging with busy workloads and team members working remotely. This session will highlight strategies that can be used to facilitate continued learning for all members of HCM team.


DME, DRESSINGS, DEBRIDEMENT AND DISCIPLINE: Practical strategies to preventing and closing pressure-injuries in the home. (CP)
Pressure injuries are among the most expensive conditions to treat in the home. Home-based providers often lack specific training to care for them. In this session, an expert in palliative wound care will engage in a case-based discussion of how to move beyond classifying pressure injuries to grasping and executing multi-faceted preventative and therapeutic approaches. Participants will learn a framework of thinking that can guide decisions about durable medical equipment, dressings, debridement, antibiotics and when to involve other disciplines.


DME: Ordering with less stress and more success in HBPC (CP)
Ordering durable medical equipment can be time consuming and frustrating for providers in home-based primary care. Come learn some of the tips and tricks to help save you time and headaches when ordering DME for your patients.


Leveraging the HRE and Artificial Intelligence for HaH Patient Selection (CP, HaH)
Identifying and prioritizing home hospital patients continues to challenge healthcare institutions. Burdensome manual chart reviews have been the main strategy for many programs. Discover from physician and nursing leaders how leveraging the EHR saves time and improves team communication and clinician satisfaction. Learn how one program developed a predictive model to assist with selection and prioritization of home hospital patients. We will also discuss potential pitfalls of artificial intelligence especially as it relates to DEI.


Social Determinants of Health- The other vital sign (PH,EQ)
Social determinants of health is well known as a variable that can affect one's health and wellness. However most times in practice social determinance of health is not assessed in the way the traditional vital sign will be assessed. Further focus on the various aspects of social determines of health can lead a practitioner to identify underlying circumstances that impact their patient and their ability to adhere with an established plan of care. This session discussion will challenge practitioners to think of social determinant of health as other measurable assessments and develop ways to incorporate interdisciplinary approach when addressing in the clinical setting.


Pearls of Pain Management in Home Care (CP, PH, PM)
Session will be a brief talk covering high-yield topics in pain management for homebound patients. Within the confines of the time block, will address basics of chronic pain, pain assessment, pain management, concerns about pain management related to equity, and legal considerations around pain management medications. Talk will be aimed at Beginner level attendees with limited discussion of pharmacology and medical science, primarily to link together the topics discussed.


Saturday, Oct. 29 (Day 2)

Interdisciplinary Deep Dive: Anxiety & Depression (CP, PM)
Many older adults who suffer from depression and anxiety conceal their anguish and dismiss it as 'part of getting older' but this should not be the case. Since depression and anxiety can present differently in the older adult population, it is important to recognize symptoms and differentiate between these common mental health conditions and their treatment. This session will use an interdisciplinary team perspective to discuss the emotional complexities of the aging process and enhance the clinical understanding of two often overlooked mental health conditions found in the HCM practice setting.


Creating a Robust Onboarding Program for New Providers in Home Based Medicine (ED, PM)
Outline the creation of an 5-6 week orientation to home-based medicine, subsequent training program, and a 1-year mentoring program. Highlighting the ongoing challenges and development of the orientation process will assist other practices in developing their processes. Through discussing the roles of multiple team members, we will highlight our methods to create a well-rounded home-based primary care clinician.


Post-Acute Home Care Initiative - New Directions in Transitional Care for High Utilizers (PM, PH, VA)
Nationally, it has been estimated that the top 1% of healthcare utilizers account for 21% of healthcare expenditures nationally. The Southern Arizona VA Healthcare System developed a Post-Acute Home Care program to address this unique population through a 90-120 day multidisciplinary program designed to decrease ED utilization and hospitalizations though improve a patients capacity for self-care. The presentation would discuss "high utilizers" as a population and review different approaches to working with this population.


Not your grandmothers Nurse- What does nursing look like in an Acute Care at Home Model (PM)
The role of nurse in home care medicine has evolved from the traditional home health nurse to exciting positions that require honing nursing practice while learning new nursing skills. Building on nursing fundamentals, this session will explore the basics of new roles in acute care at home, review adaptions of nursing process, illustrate the importance of collaborative practice using new techniques, and share clinical pearls for success in providing holistic patient care.


ED In Home: A Novel Approach to Improving Health Equity & Access to Care - (PH/EQ)
Primary care and specialty practices have struggled to manage the surge of patients seeking acute care. Emergency Departments (EDs) are experiencing historic overcrowding leading to delays in care, staff burnout and patient dissatisfaction. During the Covid pandemic, patients are fearful of presenting for care, especially the elderly and those at risk with co-morbid conditions.


Market Trends  (PM)
HBMC is currently the fastest growing area of healthcare, mainly in the for-profit sector. Just like academic and non-profit HBMC practices, for-profit sector has same goal -- to bring care to more frail seniors who benefit from model. With more resources to take advantage of, there is a huge opportunity to bring HBMC to more seniors. There are also potential risks to the integrity of the care model/field, workforce, patients and caregivers, if the model is not sustainable or executed based on best practice. Why is this important to you and your practice?


Driving Practice Growth through Marketing and Media Relations: Promoting your Practice and Home-Based Care in your Community (PM)
How do you make sure your community knows about the important work you are doing and understands the value of home-based medical care? In what ways can marketing and the media be leveraged to drive growth in your practice and increase the number of homebound and home-limited patients being served? In this session, you will learn how to effectively promote your practice to community stakeholders and media outlets through marketing and compelling messaging, including how patients and the wider community benefit from this unique model of care. Session participants will receive a helpful checklist as a takeaway.


How to Attract and Hire a Diverse Staff that Reflects your Patient Population
America is a rapidly diversifying nation, and the U.S. Census estimates no single ethnic or racial group will represent a majority of the U.S. population by 2055. Healthcare has already identified -- and is grappling with -- how this continued shift is creating unique care needs and challenges. To provide high-quality care and improve patient outcomes for diverse patients and communities, it is essential that providers, practice staff, and leaders represent the patient population served. This session will provide recommendations, tools, and key action steps that can be taken to attract and hire a diverse staff reflective of its community and patient population.


Teaching at the Bedside and Beyond: Creating a Culture of Education in Your Home-Based Primary Care Practice (ED)
This session will focus on the experience of an interprofessional learner participating in a home visit rotation. Utilizing tools from the Educator's Toolkit, we will simulate a home visit day including pre-visit independent reading and modules, bedside teaching tips, and post-visit debriefing. We will also discuss creating a culture of education in a home-based medical care practice. Finally, the session will also feature updates to the Educator's Toolkit, focusing on content updates and increased navigability and access.


Prioritizing Priorities - Standardizing a scalable workflow for person-prioritized goal elicitation and person-directed outcome measurement in home-based primary care models.(PM)
Person-centered care is care anchored in 'what matters most' to each person. In medically complex patients, person-prioritized goal-directed care improves patient satisfaction, increases adherence, and reduces utilization costs. Despite these benefits, person-prioritized goal-directed care has not garnered much traction outside of academic medicine for a multitude of reasons. This session will address practical considerations for home-based primary care groups looking to standardize person-prioritized care across their patient population.


Policy Issues Impacting Home Care Medicine (HP)
This session will cover public policy issues affecting home care medicine — both legislative and regulatory. It will also highlight the work that the public policy steering committee, work group, and task forces have accomplished thus far in 2022.


Redesigning HomeCare ACO Workflows to Save Time, Optimize Documentation & Improve Experience (PM)
Current documentation and technology platforms fail to support clinical workflows for complex home-based care. This mismatch leads to information loss, low RAF scores, and low reimbursement. The authors implemented an interdisciplinary process supported by a care orchestration platform to drive more complete documentation, close care gaps, and streamline workflows, resulting in an increase in RAF scores from 2020 to 2021 for ACO patients whose clinicians used the platform compared to clinicians that did not.


Medication Management in Advanced Dementia (CP)
A presentation of current therapeutic modalities to be used in the management of patients with moderate to advanced dementia. This will include patients diagnosed with or exhibiting clinical signs of behaviors and psychological symptoms of dementia (BPSD). I will offer a thorough review of different classes of drugs useful in management of these patients.


No Place Like Home: Hospital at Home as an Equitable care model (PH/EQ, HaH)
In the spring of 2020 Northwest Kaiser Permanente and Medically Home joined to create a HaH model called KP at Home. A fundamental aspect of the KP at Home model is to address aspects of health equity. Since inception we have cared for over 1500 patients with acute hospital illness and an ADC of 15 patients daily. This presentation we will discuss specific metrics that could be reliable indicators of equity in the HaH model and how the [email protected] model measures these. Finally, we will review how our model of care addresses specific equity factors so that other programs can utilize.


Managing Dementia in the Context of Multimorbidity: Insights from Home-Based Medical Care (CP)
(No description available)


Moving from “Checking the Box” to a True Culture of Quality and Quality Improvement in Home-Based Primary Care
Leaders from the National Home-Based Primary Care (HBPC) Learning Network (LN) will: 1) provide an overview of the LN and the importance of quality improvement and continuous learning for HBPC, and; 2) leaders from 3 LN practices will provide concrete examples of how engaging in continuous learning helped their practices to evolve from a culture of “checking the box” on quality measures to creating a true culture of quality improvement in their practice


Healthy Sleep in Older Adults (CP)
This presentation will be an overview of the physiology of sleep, the changes that can occur with aging that impact healthy sleep, and the evidence-based approach to improving sleep as people age. It will include pathological links to dementia. The clinical pearls will focus on improving sleep hygiene and discourage the use of medications with poor efficacy.


The State of the Science of home-based medical care: What we know (and what we need to know) about a rapidly growing field (CP)
Presenters will synthesize evidence related to home-based medical care (HBMC), including updates to their prior AAHCM 'State of the Science' sessions and recently published systematic review. Presenters will survey COVID-specific HBMC research to describe where home-based care has grown, as well as identify areas where evidence has not caught up to current practice. The presenters hope to engage the audience to identify areas of growth not found in medical literature and share insights on future research directions.


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