Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Adam Burrows, MD, Medical Director of Upham’s PACE, an organization of the Upham's Corner Health Center. A geriatrician and assistant professor of medicine at the Boston University School of Medicine, Dr. Burrows is active in promoting and supporting integrated models of community-based care for frail and disabled older adults. He is a member of the National PACE Association’s (NPA’s) Board of Directors and serves as chair of the NPA’s Primary Care Committee and editor of the PACE Medical Director's Handbook. Additionally, Dr. Burrows is a health services consultant for the Rural PACE Project and is chair of the Rural PACE Ethics Committee.
Learn more about the Keep Up With PACE Podcast by visiting: https://careventionhc.com/insights/podcasts/
Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Adam Burrows, MD, Medical Director of Upham’s PACE, an organization of the Upham's Corner Health Center. A geriatrician and assistant professor of medicine at the Boston University School of Medicine, Dr. Burrows is active in promoting and supporting integrated models of community-based care for frail and disabled older adults. He is a member of the National PACE Association’s (NPA’s) Board of Directors and serves as chair of the NPA’s Primary Care Committee and editor of the PACE Medical Director's Handbook. Additionally, Dr. Burrows is a health services consultant for the Rural PACE Project and is chair of the Rural PACE Ethics Committee.
Learn more about the Keep Up With PACE Podcast by visiting: https://careventionhc.com/insights/podcasts/
Hello and namaste everyone. I am Dr. Ankur Patel, Chief Medical Officer, Tabula Rasa HealthCare and the author of the book Age is Just a Number. Welcome to the episode of Keep Up with PACE. I'm pleased and honored to introduce today's guest, Dr. Adam Burrows. Dr. Burrows has been the Medical Director of the Upham's PACE, the PACE organization of the Upham's Corner Health Center, since inception in 1996 and has guided the program's expansion to three PACE centers serving older adults throughout the city of Boston. Dr. Burrows has been active nationally in promoting and supporting integrated model of community based care for frail and disabled older adults, serving as the chair of the National PACE Association's Primary Care Committee, editor of the PACE Medical Directors Handbook, Health Services Consultant for the Rural PACE Project, and member of National PACE Association Board of Directors, where he is the first physician to serve as chair. Dr. Burrows developed and chaired the Rural PACE Ethics Committee and is a long standing member of the Massachusetts PACE Ethics Committee. Dr. Burrows is a graduate of Mount Sinai School of Medicine and completed his medical residency at Boston City Hospital, chief residency at Boston VA Medical Center, and geriatric fellowship at the Harvard Division on Aging. He is a member of the Boston University Geriatric Faculty and Assistant Professor of Medicine at Boston University School of Medicine, where he twice received the Department of Medicine's annual Excellency in Teaching Award for the community based faculty. Namaste, Dr. Burrows, and welcome to Keep Up With PACE. Thank you, Ankur. Pleasure to be here. So the journey of thousand miles begins with a single step. Tell us more about your PACE organization and their journey. As you mentioned, Upham's PACE is the PACE organization of the Upham's Corner Health Center. The Upham's Corner Health Center is a federally qualified health center in Boston. It's a small health center founded in the early nineteen seventies. Like other community health centers in Boston, the health center has always been staunchly independent and has resisted being absorbed by any of the medical systems in the city, but has long had a mission of caring for older adults. It's one of the few health centers with a certified home health agency. In Massachusetts, t he East Boston Neighborhood Health Center had the first PACE organization in the Commonwealth. It was part of the original demonstration to replicate the unlocked model, and based on the success of that original demonstration, Massachusetts wanted to replicate PACE elsewhere in the Commonwealth, and Upham's Corner Health Center was one of those providers who was given that opportunity. There are now eight PACE organizations in the Commonwealth, so it launched its PACE organization in 1996. Nice. A serendipitous convergence of interest that I had become familiar with the PACE model through my training and learned that Upham's Corner was launching PACE, and I approached them and introduced myself and said, I'm familiar with PACE. I am a Fellowship Trained Geriatrician. I'd like to get involved at the ground level and help guide your program's growth. Right now you have three centers, so how many total participants you have? We have about 300 participants across southwest centers serving the urban core of Boston on this side of the harbor. East Boston is across the harbor, and there's also another PACE organization serving southern parts of Boston, the Harbor PACE Program. And then there's across the river, across the Charles, there's a Cambridge program. Okay, so how far are each centers from each other? They're close. Boston is a very small city, so we sort of triangulate our service area. We have one center in Dorchester where the FQHC itself is located in the neighborhood of Dorchester. We have one in Roxbury, it's probably just about 2 miles away, and then one in Jamaica Plain, another 2 miles away. And it's always great to talk to a fellow geriatrician because we are a rare breed. There are only 7,000 of us nationally, and we need around 33,000 geriatricians. Why did you decide to go into geriatrics and how we can encourage more medical students and residents to go into geriatrics? So I'll tell you the story of how I became a geriatrician. I knew I wanted to do urban primary care. I trained at the Boston City Hospital, which is now known as Boston Medical Center, but I trained at the Boston City Hospital, and I was in their primary care medicine track. And as a senior resident, I picked up a second panel of patients. I had a clinic, but then I picked up a second panel of patients, which was a home care panel, and that got me out of the hospital, into the neighborhoods of Boston, into people's homes. And I've always had an affection and affinity for older adults, and this is when sort of geriatrics is emerging as a field, I think. And I saw it as an opportunity to do urban primary care with a focus. I should also mention that I have a somewhat rebellious or countercultural nature, and medicine was in my family. My dad was a surgeon, my brother's a surgeon. And so even becoming a primary care doctor was sort of a rebellious move within the family. And then to go into geriatrics at a time when people were going into more, I don't know, established subspecialties was also an act of rebellion. What I liked about geriatrics was taking care of the whole patient. It really allowed me to use all my interests, not just take care of medical problems, but take care of the person. Had to be a broad based generalist and broadly competent, which appealed to me. And then, as I said, serendipitously quite fortuitously, the PACE model was emerging during my chief residency year, and then through my fellowship, I worked moonlighting for the East Boston PACE Program, as I mentioned, the first PACE organization in the Commonwealth. I worked moonlighting for them on nights and weekends and learned PACE from one of my mentors, Dr. Jim Padula, and from another of my mentors, Dr. Jim Taylor, the late Jim Taylor, who was the Chief Medical Officer for the East Boston Neighborhood Health Center. So I became familiar with the PACE model and then saw that as an ideal way of practicing urban geriatrics, an ideal way to take care of a very vulnerable older population in their homes, in the community, honoring their preferences. So I've been very fortunate to have had my career sort of aligned with the emergence and growth of the PACE model. That's great. And I always think, like, to be a PACE doctor especially, you need not only to understand the patient's body, but also you need to understand their mind and connect with their soul. And I have seen turnovers in medical directors in PACE. So what is the secret of Adam Burrows longevity in PACE? Yeah, I agree with you entirely, Ankur. One of the things I realized recently is that like many doctors, I read up to date to learn how to take care of my patients medical problems. But I read literature to learn how to take care of my patients. Taking care of patients is very different than taking care of their medical problems. In order to be able to take care of their medical problems, you have to relate to them as human beings. And another one of my mentors, Dr. Bob Master, talks about relational medicine - developing relationships. So the PACE model gives us this extraordinary opportunity to develop very close relationships with our patients. Not just our patients, but with their families, their caregivers, their households. And I think that's what's sustaining. That you develop these relationships. You have the resources of this extraordinary model to apply to take care of patients. I like to think about PACE as a concierge model of care, that we have these relatively small panels of patients that we take care of, often in collaboration with a nurse practitioner, with the full resources of an interdisciplinary team at our disposal. The irony, obviously, is that we're practicing concierge medicine for a marginalized population, for poor, older, disabled population that's often marginalized, often taken care of older adults of color. And yet we're able to practice concierge medicine. We're able to develop these relationships, see people frequently. And I think that's what has sustained me in my role as a medical director and as a geriatrician. One of the pieces of guidance that I give to medical directors who are coming to PACE or growing into the PACE model is stay grounded, stay at ground level, continue to take care of patients because that is what will sustain you. It's also what will give you credibility with your staff and with your organization and with the outside world. PACE offers enormous flexibility, right? Every day is different. Every day I have an opportunity to take care of patients at the PACE Center, do home visits around at the hospital, go to the nursing facility, but I also get to supervise my staff. I get to fulfill administrative responsibilities. So there's a lot of diversity in the work, and I think that's what sustained me. I think the other thing that has is the opportunity to be in a leadership role in my organization, to have that authority to guide what the program looks like, what our program looks like. There is a PACE culture that you're familiar with, right? There is a PACE culture, but each PACE organization has its own microculture. And even within each PACE organization, each PACE team has its own microculture. So I've had the opportunity, I think, I like to think, to influence what our culture looks like. True. And I remember in our past conversation when we were talking about the culture, and especially with the IDT, everybody is different. But you mentioned that what you like most about the PACE is everyone in IDT has a voice and it's an anti-hierarchical model. Tell us some more about that. Yes, I think PACE is deliberately anti-hierarchical. The visionaries who founded PACE back in San Francisco, they were wary of PACE becoming overly medicalized, right. Marie-Louise Ansack and others at On Lok, they want to avoid PACE becoming too medicalized. And so they developed this interdisciplinary model of care where each member of the team has equal standing. And the PACE model only really works if everyone around the table has a voice and is contributing. They have to contribute from their individual discipline, whether we have eleven disciplines in PACE, and then we add more just to make it more complicated. But everyone has to be prepared to contribute from their discipline. But that will never be sufficient. You also have to be willing to engage in all the creative problem solving and care planning that makes the model work. So you have to also be willing and able to speak outside your discipline. So as a leader in PACE, you want to cultivate that culture where everyone on the team feels empowered to speak up because everyone on the team, the whole reason there is this interdisciplinary model is that every member of the team has an important piece of the puzzle. And just as you were suggesting, the doc i s one member of the team. Unlike other teams in medicine, surgical teams, for example, the doc is not at... And I'll send this record to your family, too! No, I'm sure there's a reason why it's structured that way in the surgical world, in the hospital, but here in the community, it's very different. It's a different culture. And in this culture, the doc is not at the top of the pyramid of the team. The doc is one member of the team. I agree. And that's the beauty about the PACE. I always say that it's easy for me to take care of the sickest patient because I have an amazing team to back me up. And especially with the social needs and other social determinants of health in PACE. Another thing I always say is now we are hearing about the age friendly health system and the 4Ms and what matters. And when I was reading this, I was happy that it's coming out. But in PACE, we have been doing this since the 70s. Yeah, I agree. I mean, PACE has been in the vanguard of person centered individualized care. Right? And just as you said, one of my mentors early on in PACE was Dr. Willie Orr, who was the medical director for Total Long Term Care in Denver and he talked about, and he talked about this in an early PACE video, how our work as geriatricians becomes so easy, i f we have the resources and the members of the team addressing all those social and functional determinants of health. It's very easy to take care of the heart failure, to take care of the chronic lung disease, whatever it might be. Like if someone's addressing the food source, if someone's addressing the functional needs, someone's addressing the medications, if someone is addressing all that causes individuals to become insecure and to worry. I think that's one of the great benefits of PACE. It confers this enormous sense of security, not just on the individual, but on the household, that their needs will be met. So when you have a team and a model doing that, it's very easy to take care of these very complex chronic conditions. I agree. From our brief conversation, it definitely sounds like that you have been influenced by a lot of your mentors. So what tricks do you use right now when you are a mentor to medical students and residents and kind of convince them to go towards geriatrics? So geriatrics, and PACE in particular, gives us the opportunity to practice primary care medicine in an ideal way, in an old school way, where we have relationships with our patients, we have relationships with their families. We are established in the homes and the communities and we're responsible for their care. Their care is not divided up among specialists. We are managing their chronic conditions. We are the first point of contact, and ideally, we're taking care of them across the entire continuum of care. Healthcare has become so balkanized, where you have a different specialist for every chronic condition. When you move across that continuum, you have a primary care doc in the office, you have a hospitalist in the hospital, you have a SNFist in the nursing facility, y ou have a hospice provider at end of life. Here you have an opportunity to practice primary care really in an old school way, the way I think it works best where you have relationships, you're caring for the individual across the entire continuum. So when we have trainees, when we have residents and fellows work with us, we try to model that and demonstrate that to them and they're won over. My docs are former trainees who work with us as fellows. They now bring fellows and residents to our PACE center. I wish we had more PACE centers so I could hire them through our program. And hopefully we will expand access and be able to do that one day. But I think in the same way I was turned on leaving the hospital and seeing what was possible. When we bring trainees out, they see what's possible and they can see a way of being a doctor that fulfills their goals. Yeah, I think mentorship is very important. And I will embarrass you here a little bit. You may not know, but you have left a very good impact in my life and what I have done in PACE. You may not remember, but in 2016, the Summer Conference of NPA Summer Conference was in Charlotte, North Carolina. And I was like three or four months in PACE and thinking about why I signed up for this job. Is this for me? And that conference, I met you and we talked and I had three or four other medical directors who were all like, less than six months in PACE. And our conversation was like, why did we sign up for this? And we all talked to you and thank you for that time because you talked with us for 20 minutes. But that 20 minutes changed all of our lives in PACE. That we went back with a different mindset where we were questioning ourselves, t hat why did we sign up for PACE? We walked out more like, we belong to PACE. This is for all the listeners, that in PACE we are family. Everybody is ready to help each other. I have not met one single person who has said no to help. And what I always say, if you cannot see where you are going, ask someone who has been there. And I want to thank NPA for organizing the Summer Conference and the Annual Conference because that's how we get connected. And this is a medical director, I'm just giving my personal story. But if you're occupational therapy, if you are physical therapy, connect to other fellow physical therapists and occupational therapists. Because sometimes in PACE we feel like we are on an island and we don't need to be on the island, just talk. If you go to a conference, the goal should be to get five cell phone numbers. So when you are feeling alone, text them. And we are here to help each other out. And Dr. Burrows, thank you personally for helping me and a lot of other medical directors. And indirectly, you may not know, but you have definitely helped us. Well, thank you. I appreciate that, I really do. And one of the reasons I got involved in NPA in the National PACE Association, because of the sense of community that NPA is established across all PACE organizations. PACE is what I like to call an open source community. There's no intellectual property. Whatever I have learned or whatever anyone else has learned, my mentors, my teachers, is shared. Right. Because a PACE medical director sitting in Wichita wants a PACE medical director sitting in Muskegon to succeed. Yes, that has been characteristic of PACE from the get go. The National PACE Association, NPA has been the vehicle, the structure for that. Every PACE organization in the country belongs to NPA. There's a period where that was not the case, but now every PACE organization in the country belongs to NPA. It is not just our trade association, but it's the mechanism, the vehicle for community. And just like you said, I have a sense of collegiality, a sense of relationship with medical directors across the country, leaders across the country, docs and NPs across the country. Yeah, I agree. With NPA, I think they have given a great platform. And I think that one of my favorite part about the NPA conference is more the Summer Conference. And thank you for doing that conference because it directly geared towards medical directors and quality directors or managers. So that's how we get a chance to meet one on one in a small group and make friends and colleagues and grow. So talking about NPA, you served as a chair for the NPA Primary Care Committee. So what is the role of NPA's Primary Care Committee? Well, it's really evolved. So the Primary Care Committee is the committee of PACE medical directors. So if you're a PACE medical director, you're automatically a member of the PACE Primary Care Committee. And it's really evolved. I think it's become much more structured with time as the PACE model has grown and as NPA has grown. Now there's a lot of work done by subcommittees. There's Practice Guidelines Subcommittee, there's the Medical Director's Handbook Subcommittee, there's Education Subcommittees. The real goal really is to share best practice and to share knowledge and wisdom that's acquired by one PACE organization across the entire community. And just as you said, to provide a place for medical directors to learn from one another. And then with the Medical Director Handbook, because that was like the Bible I was given by my executive director first day I walked into my PACE Center. And I know you have been the editor of the PACE Medical Directors Handbook, how was it started, like who decided let's just create this that will help other future medical directors? You know, I can't remember how it started, actually. I can't remember if the idea was brought to my attention or if I brought it to NPA's attention. I mean, there was a recognition that there was a body of knowledge that PACE medical directors needed to access to do their jobs well. And we were sharing that information informally. So there was clearly need to codify it. I offered to edit it and what I did was I recruited PACE medical directors to write chapters about topics that were of particular interest to them. And I contributed a few chapters. And it's now in its third edition, it's available online on the NPA website. Other medical directors have joined as co- editors, and it's also sort of the foundation for the Medical Directors Essentials Course that we launch at the Summer Conference. And hopefully it will also become the basis for some kind of accreditation of PACE Medical Directors too. This is awesome because I'm just thinking about it because when I was writing my book, Age Is Just a Number, and I go through each chapter, but I'm still like calling my geriatric colleagues, like, I have covered this much in full. What else do you guys think I should add? So for this chapter by chapter, did medical directors just sit having a beer and be like, let's just talk about quality metrics and what we want to add to it? Didn't quite flow like that. There was some pulling and tugging involved. I wanted it to be a document with multiple authors. I want it to have multiple voices in the same way that we have multiple voices on the IDT. I wanted the voices of multiple medical directors involved. So there was some arm twisting to get people to contribute, but in the end, people did it willingly. I think we realized in subsequent addition is that there were new things that we had to add. We had to add rural PACE, we had to add end of life care. So we added obviously more topics. And we've been very fortunate that medical directors like yourself have come to the model and brought things to it, brought interests, brought experiences. And in that way I have enhanced the model and have also shared that through the handbook and authoring chapters and teaching others. So for the listeners, the PACE Medical Director's Handbook is the book that's available on NPA. It's online, and for any new PACE Medical director, we use it as a Bible, and then after that, we use it as a reference book. So if you have a new medical director, please, this is one of the first things that you want to pretty much send with the welcome package that they can start reading. You have been involved with NPAs in different roles, and I always say that clinicians and specialty physicians also need to take a leadership role and sit on the table. You have been a member of the NPA Board of Directors, but you have been the first physician to serve as a chair. So tell us about your role in that. Well, I began my tenure on the board as an ex officio member of the board, the chair of the Primary Care Committee. So that's how I was first interested and became involved with the board. I was interested in taking a leadership role, had the support of others on the board to do that. Now what I wanted to bring to my tenure, and I served as chair of the board from 2018 to 2020, not so much my identity as a physician or a medical director, really, but my identity as a clinician. Most leaders in PACE have a clinical background. I think that's one of the great virtues of leadership in PACE, of leaders in PACE, they have a clinical background, but many have moved into exclusively administrative and leadership roles because they've had to. And that's fine. But I wanted to bring sort of the same orientation I have on an interdisciplinary team to the board. To make sure that we include all voices on the board that we heard from everybody. I like to think I chaired board meetings in the same way. I would like our facilitators to lead our daily and weekly team meetings, making sure that all voices around the table are heard. When I started my tenure as chair, Shawn Bloom, the president and CEO of NPA, and he asked, what do you want to achieve in your two year term as chair? And I named three things. Number one, I want to bring Trinity and InnovAge back into the fold. For different reasons they had left. That eventually came to fruition, not during my tenure, but after. I said, I want to elevate diversity, equity, and inclusion to a point of prominence in NPA. And this was 2018. This is before the death of George Floyd and before the protests. I was very much aware we serve disproportionately in PACE communities of color, that our leadership structures don't always represent or reflect the populations we serve. And then we had certain obligations, therefore, to address that. So one of the things I'm most proud of from my tenure, I like to think in terms of legacy, is that we establish a Diversity, Equity, and Inclusion Council at NPA. Made up of extraordinary individuals, workers from PACE organizations around the country, as well as NPA staff. And I think, once again, the way that NPA does everything, hopefully they'll also be sharing best practice across PACE organizations. Because I think every PACE organization wants to do better at this. Right? We all want to do better at this, but how do we do better? So just like everything else in PACE, who's doing it well? And how can they share what they've learned? How can they share their wisdom and experience? How can they establish best practices others can emulate? So that was the second thing I wanted to achieve. And then the third, really, was to make sure that we address the integrity of the model even as PACE was growing and expanding. Thank you. I did not know that, but thank you for your contribution. And especially with bringing in diversity. It has always been near and dear. One of the other opportunities that chairing the board gave me, it does give you a pulpit right. Twice in your tenure, you're allowed to address the entire NPA membership. And so I was able to do that at our two annual conferences and at the first conference in Portland, I spoke about the radical nature of PACE. PACE really has an opportunity to be transformative in the ways that you mentioned earlier, really shifting care from high tech, using resources that might otherwise go to expensive care to address the social determinants. PACE really has an opportunity to be radical in its approach to healthcare and we should stay true to those radical roots. And then my second opportunity was in New Orleans where I tried to build on that and talk about race, something that obviously is uncomfortable to talk about. We need to talk about it, we need to address that. We need to be aware of it and cognizant of it through that. And after that we launched the Diversity, Equity, and Inclusion Council. Thank you for doing that. And when we were talking about sharing the best practices in PACE, and that's the reason for this podcast, that the whole goal was to increase PACE awareness, shares the best practice so we can learn from each other and to all the listeners, if you have a story to share, please go to CareVentionHC.com and please share your story or put your name and number and my team or myself will contact you back. Because here what we want to do is share your story. Not everybody all the time can make it to NPA and look at all those great presentations that have been done. So we'd love to use this as a medium where you can share your story and talking about thinking outside the box, the beauty about talking to people in PACE like you, I always learn something new. We always say that let's think outside the box. But implementing those thoughts is even more critical. And at your program you have implemented this out of the box or out of the universe kind of model, which is a personal care worker program. What is it? And I want to hear all about it. This is our version of consumer directed personal care. I mean, it's a hybrid model. It's a hybrid consumer agency directed that's sort of custom fitted to PACE, but it really draws on the principles of consumer directed care. So just to go back and to let you know how I got introduced to this. So Adam before, sorry to interrupt you, but before you go into that, can you explain? Because I don't think the viewers know what is direct personal care either. I was a skeptic when I first learned and heard about this. And I think when a lot of people first hear about it, they greet it with a certain skepticism. Of course, now I'm a champion of it. And I think that's often what happens, right? Skeptics become zealots. But for ten years I wore two hats. I was the medical director of our PACE organization, but I also worked for the Commonwealth Care Alliance and Commonwealth Care Alliance was an organization founded by one of my mentors, Bob Master, with a goal of bringing integrated care, integrated Medicare and Medicaid, fully integrated care to vulnerable disabled populations. And Commonwealth Care Alliance operated a senior care organization, which is a Massachusetts specific integrated care model for older adults, not just those who are nursing home certified like in PACE, but across the spectrum. But Commonwealth Care Alliance really has its goal to ultimately serve younger disabled individuals. And eventually it did that through another program launched in Massachusetts, another integrative program called One Care, which is for younger duals ages 21 through 64, whereas Senior Care Options is 65 and older. But those who developed Commonwealth Care Alliance were advocates, advocates from the disability community. And it has been a principle of the disability community, of advocates for persons with disability, that those with disability should control that which is most intimate, personal care in particular. And it really emerged, consumer director personal care really emerges from the civil rights movement. In the 1960s and 70s, and as the civil rights movement moved into the disability space, individuals with disability wanted to control their destiny, and they want to control who took care of them and how. So consumer directed personal care is the idea that an individual identifies, hires, trains, supervises, and fires their personal care worker. The individual who is responsible for supporting their activities of daily living and their IADLs. So consumer direct personal care first developed among the younger population and then has moved somewhat uneasily into the older population. But through my work with Commonwealth Care Alliance I became exposed to it. Through, again, learning from others, in particular a nurse practitioner named Mary Glover and others. I learned how powerful a concept this is. If you really want to honor principles of person centered individualized care, you want to give individuals an opportunity to control who is laying hands on them, who is bathing them, toileting them, dressing them, those intimate functions. You want to grant control of that to the individual. And that individual could be a family member? It could be anyone, typically a family member or friend. It could be anybody. So consumer directed personal care is established in all 50 states and the District of Columbia. So now Medicaid dollars can go to allow individuals with this ability to hire their own workers. And it's called different things in different states. In Massachusetts, it's called the PCA program, the Personal Career Assistant program, but it's called different things in different states. So while working at CCA, I saw how powerful this can be, because if you think about it, if you grant the individual some control over their personal care, by extension, you are granting them greater control over their whole healthcare delivery. Exactly. And so if you accept the principal that they can control who's doing the critical work of community based long term care, the critical personal care work, then you're also granting them greater control over their entire health delivery system. So one of the advantages I already see here is it's not like, for example, if we use this in PACE, it's like rather than two or three different aides going to Miss Smith or Miss A or Z's house, this could be Ms. Z's daughter. This could be a neighbor or somebody she knows. And better continuity of care. Exactly. There are a lot of advantages of adopting this hybrid approach to consumer directed care. The challenge is, how do you make this work in a PACE context? For a few reasons, right? First, the regulatory environment. So to move consumer directed personal care into PACE, you have to make sure that any worker meets PACE personnel regulatory requirements. Okay. Those are not necessarily required in the pure Medicaid personal care program. It's up to the individual to decide whether they want to do health and safety screening. It's up to the individual whether they want to do a criminal background check because it's consumer directed. Okay. But there are certain obligations that we need to meet in PACE. That's number one. So you have to make it work in that personnel context in PACE. The second is PACE is an interdisciplinary team model. And in the pure consumer directed model, personal care is kept at arms length from the medical system and from the healthcare system. But in PACE, you want to integrate it into the interdisciplinary team model. So how do you do this? The way that we develop this is that any individual, any participant can identify someone to be their personal care worker. And the health center, our sponsoring entity, will hire that individual. That individual will be hired with wages, benefits, and their employment, though, will be limited to that one person. That one individual that they're caring for. They will have the benefit of orientation, education, training and supervision from the different members of the team. And it's co-directed. So the team, together with the individual, directs the care. And if the individual can't direct the care, then a surrogate, a healthcare proxy, someone else's surrogate will co-direct it along with the team. And they do go through the orientation? Li ke let's say we hire, I'm just making up, hire a home health aide or a nurse who goes through the PACE orientation. They go through the same orientation? Everything. They are an employee of the health center. They're a member of the PACE team just like anybody else. Okay. There are a number of advantages. First of all, the individual is typically very comfortable with that person. I agree. You have sort of built in cultural and linguistic compatibility. And we serve five language groups in our PACE organization. So you have cultural and linguistic, at least compatibility. A personal care worker can do things that a home health aide cannot do. So home health aides, for example. Like what as an example? Yeah so home health aides cannot administer medication, for example. Okay. But in a consumer directed model, the personal care worker could do whatever the consumer wants them to do. Oh okay! Our personal care workers can help with medications. They can transport, drive participants places. They can shop for them, handle their money. They can, again, do whatever the consumer wants. So that is the biggest advantage actually, because I'm just thinking about my own example that I had a patient who was very non compliant with insulin and every day when they were not at the center, my nurse used to go and give insulin to the patient because the aide cannot give the medication. So in this case their personal care person can actually give insulin to the patient? Absolutely. They can do whatever the individual wants them to do or the individual surrogate can do with the training and supervision and support of our interdisciplinary team, whether it's our occupational therapists helping them do safe bathing or our nurse educating them about how to do safe insulin administration. So far what I understand is we have Ms. X as a participant. Ms. X can say I want my daughter, Ms. Y, to be my personal care. So the PACE organization will get the daughter in the center, orient them, give the appropriate training that we do for our employees. The daughter would be also part of the employees of the PACE organization and get the benefits, and that daughter now can take care of the mother, Ms. X, and just do everything that an aide and more can do. So in the same way, does it need to be employed or you can also do a per diem model? But we want that individual to be an employee. Okay. We want that person to be part of our system, part of our organization. So how did it work? Did it come up for the care plan meetings? So the tasks assigned to the PCW, the personal care worker are just like the tasks that could be assigned to a home health aide. It's all based upon the multidimensional assessment performed by the team. And from that we develop a care plan. And the care plan calls for certain tasks to be performed to support the ADL needs of the individual. And from that come the hours that we will assign to the PCW. So it's analogous too and parallel to our home health aid department and the home health aid work. So we have a home health aid department, we also have a PCW department and each has a leadership structure. They work sort of in tandem and some individuals may have a PCW and home health aide. What the PCW does is what we would assign to a home health aide and how many hours we assign, the number of hours we would assign to a home health thing. What is the top one or two or three advantages you have seen with this program? Well, enormous workforce advantages, right. I think we're all facing workforce challenges. When you ask PACE leaders today what's the number one issue you're facing? Every PACE leader will identify workforce shortages and workforce challenges, so you're able to greatly expand your workforce. It's hard to hire home health aide. I agree. So you expand your pool of available workers. And PACE is a model of community based long term care, right? PACE is long term care. It's a community based model of long term care. And who is most critical in any system of community based long term care? It's the direct care workers. So you greatly expand your pool of direct care workers. So that's one advantage, I think workforce, the flexibility of what they can do, the times that they can do it. It's hard to get home health days into the home early or late or even overnight. But if you have a PCW, they have more flexibility. And then as we talked about the cultural and linguistic compatibility too. Yes, I can see that. We saw this play out during the pandemic. So I think every PACE organization experience workforce attrition during the pandemic for lots of reasons. Our home health aides had so many other responsibilities. Our home health aides got sick, so we saw attrition in our home health aide department. We saw no attrition in our personal care worker program at all. Wow. And at this point, personal care worker hours account for well over 40% of our total drug care hours in the home. Okay. I'm just thinking because especially with different culture diverse backgrounds, I can totally see if my grandmother, Indian grandmother who speaks Hindi, and then for her like if an aide is coming who does not speak the same language, it will be a big barrier of care for her because she may not open up and talk and she may not able to explain her all needs and problems. I can totally see that a patient or a participant has somebody that she knows and trusts, it takes that care to the other level. I bet. How is your patient's satisfaction rate with this program? Oh, very high. Very high. And not only participant satisfaction, but caregiver satisfaction too. What it also does, it aligns the program, the participant and the caregiver and the household and the family. Right. We're caring for a very challenging population. Caring for a population that's at nursing home level of care, but living at home, that's hard for families. Right. But if they can also generate income from it and these are poor families, poor households. It's an opportunity for them to capture some of that revenue as household income. So it aligns all the stakeholders. I'm really amazed with this model and especially because outside PACE world, one of the biggest challenges I see is when they say, oh, my so and so grandfather or my father is going to a nursing home because of dementia, which I always think that is partially true. The other half of the truth is the caregivers just burn out and they can't handle this anymore. And even caregiver burn out when we are talking about that half of the caregivers are going through financial hardship because 50% of them goes through poor health conditions because of taking care of their loved one. So now a sick patient is taking care of another sick patient and they still have to work and everything. So this model is amazing, where a caregiver, rather than setting up, working for somebody else, still financially secure, is still working and caring for their loved ones. So on this, do you get like a pushback about, okay, you are paying them, but then where does the family responsibility and accountability come? Or abuse? Fraud or abuse of this model? Consumer directed personal care has been exhaustively studied, not in the PACE model, but outside of the PACE model. And the notion that it has higher risk of fraud, waste and abuse has been refuted by all the evidence. So there isn't fraud, waste, abuse, and there's very high satisfaction. But in answer to the question, where does a paid caregiver responsibility begin and family responsibility end? Like I said, what we're assigning as a task is exactly what we would assign to a home health aide. Except perhaps we can allow the PCW to do things that the home health aid would not do or could not do. So it functions no differently. If a family member is managing a household, then those are family responsibilities. And then the additional task is doing the personal care for the individual. I was working with a PACE organization in Iowa and sitting in a team meeting and they were talking about a participant who lived with her son. And her son was having difficulty making ends meet. He worked one job during the day, but he had the respite afforded by the PACE center during the day. But to make ends meet, he was going to have to take on a second job of working nights at Walmart, I believe. And what that meant was he wouldn't be there for his mother. And so he was bringing this to the attention of the team that I'm not going to be able to continue this because I can't make it work. I have to take a second job. Now, had that program, had a PCW program, right, a personal care worker program, they could have said, no, you don't have to work at Walmart. Work for us. Work for us and you can have a second income doing that and you can still honor your commitment to your mother. So why is this is not adapted to other PACE organizations? And what do you think the barrier is to adopt this? Well, we've tried very hard. We gave a presentation at the 2014 annual PACE Conference and we gave a presentation as part of the PACE Innovation Lab webinar series in an effort to try to persuade PACE organizations to adopt this. Some have, I think, for the same reason that I was skeptical originally. There's often someone in the leadership structure of a PACE organization or of its parent entity that gets worried for the reasons that you identify. That we're heading down a slippery slope if we start to pay family members. I think it's time to possibly give another presentation at NPA conference in 2022 because you might have updated data and satisfaction and everything. And I think it's a no brainer, but definitely I think it's more awareness and post pandemic people might have changed their mindset. So to that point, what are the lessons learned in pandemic that you will change or do something different? Well, there are certainly new ways of doing things that we learn from pandemic. We were forced to introduce technology, GrandPads and others. We were forced to meet virtually. We were forced to adopt hybrid work schedules. I think all those things will outlast pandemic. But what I really think we learned from pandemic, reflecting on it, it really proved the basic principles of PACE. And what do I mean by that? I mean, we did a remarkable job protecting our participants from COVID. But there was a cost associated with that. Our PACE organization never closed out PACE centers, but we had to reduce census and we had to reduce touches. Like I said earlier, PACE is a high touch model. We had to reduce touches. There were a few touches at the PACE center, there were a few touches in the home. And the consequence of that was, even though we were able to protect individuals from COVID, we saw all the other consequences. We saw the functional decline, we saw the loneliness and the social disruption. We had more difficulty staying on top of their chronic medical conditions because we weren't monitoring them as closely or picking up through all those touches changes in status that needed response. So in many ways, it proved the value of PACE. It proved, I think, how critical the PACE center is in the PACE model. I think a lot of people thought, oh, we can do PACE without the PACE center. But what we learned is the PACE center is critical for the social activation, the physical activation, the community. It creates the opportunity to pick up on subtle changes of status and respond to them. I think what I learned from PACE and what I learned from the pandemic - t he principles of the PACE model hold. Yes. And you can't take parts of that model out and expect it to work as well. I agree. I feel like it's the best thing is the PACE model got tested during pandemic and I think we passed with flying colors. Well, I think we passed. I think we were able to pivot. Our teams are absolutely committed. We still have the interdisciplinary teams, but we weren't able to do all the things that we were able to do before pandemic. We weren't able to work that magic of PACE in the same way. And I think there were consequences. There were consequences for participants, there were consequences for their families. So over the time now with PACE, I always say, rather than saying a new normal, why not a new better? So where do you see the future of PACE? Especially in your case? You have seen PACE in the past two decades. So how do you see PACE in the following decade? Well, I think we're continuing to see expanded access to PACE. And by the way, that's the term I like to use, not growing PACE. Growing PACE suggests that we want to grow. And what we really want to do is expand access to PACE. And we're seeing that. We're seeing new states come online with PACE. We're seeing expanded access within states. I like to cite the example of Michigan, where there's almost universal access to PACE. There are 14 PACE organizations, so it's very local and provider based, which I like. I think we're going to continue to see expanded access to PACE. And that's my dream that ultimately PACE will be an option in all 50 states and the Commonwealth and within each state, there will be universal access to PACE. Wherever you live, you can access PACE. It's not going to be the right fit for everybody, but everyone should have an opportunity to choose it. So I think with PACE 2.0 and other initiatives, we're moving in that direction and hopefully we can sustain that. I don't see the model itself changing dramatically. I'm old school, Ankur. I'm old school. So I still think that PACE is a local provider based model of care. I think PACE works best when it's relatively small. What's the right size for a PACE organization? Where you can't be so small that you're financially vulnerable. You can't grow so big that your leadership structure is no longer on the ground. Before we go into the success story, you are also involved in Rural PACE Ethics Project. Tell us more about that. One of the opportunities I had with the National PACE Association was to work on the Rural PACE Technical Assistance Project. PACE had been a very urban model, but there is an increasing need to address the needs of older adults in rural communities. So I was able to work on the Rural PACE Technical Assistance Project, which allowed rural health organizations to learn about PACE and develop PACE. I had been for a long time interested in ethical issues in PACE and a long standing member of PACE Ethics Committee shared among three PACE organizations in Massachusetts. And I had continued to conduct a PACE ethics workshop at the Summer Conference. And after one of my PACE ethics workshops, I was approached by some of the people I've worked with in the Rural PACE Project who said, we see a need for PACE ethics committees, but yet we don't have the resources ourselves to develop it. And so what I propose is, well, let's develop a Rural PACE Ethics Committee where we share resources. Twelve years ago now, we developed a Rural PACE Ethics Committee. It's made up of eight rural PACE organizations. Each PACE organization commits to participating in our meetings every two months. We now do them by video conference. Each PACE organization makes a commitment to identifying someone outside of their PACE organization, but from their community, to be a community representative on the committee. And it's a very case based approach. So each participating organization commits to presenting a case on a rotating basis, to writing up a case narrative de-identified. We distribute that and then we meet for an hour and we give guidance and education to the committee about whatever ethical issue they are facing. So is it only this is for that eight PACE organization or somebody in New Jersey who is having ethical dilemma and want a consult? Can they reach out to you? Well, they can reach out to me, but the committee is really for the rural PACE organizations that are part of it. But I think it's a model for what others can do as well. I think having access to an ethics committee is critical. And as I mentioned, I really favor a case based approach to this. The idea being that everyone learns from that case and that you take that learning back to your team and your organization. And the real goal, really, is to make PACE ethics committees obsolete, so that individual teams can recognize when they're experiencing moral distress. They can then identify what is the ethical tension, the ethical conflict, that's causing that moral distress and be able to elevate that problem and discuss it as a team. And teams experience moral distress for lots of reasons because there's differences of opinion on the team about what ethical principle to prioritize. Uncertainty about what they should do. Ethics is all about should questions - what should they do? So to be able to have access to a sounding board, right? Yes. Really to be able to present that case, if only to be reminded that you're doing the right thing as hard as it is, or that you did the right thing. Yeah. Even if you're not happy about what the outcome was. I think it's critical because most of the tension and conflict we might experience really comes from differences of opinion about what ethical principles to prioritize. Typically there are issues of safety and risk and some of the team are uncomfortable with risk. Having access to ethics committees helps you understand how to address those issues. Now we are towards the end of the show and before we go to the Rapid Five Round, we all listeners and myself, we love to hear PACE success stories. Do you have any to share with us? Yeah, I'll tell you one that I'm particularly proud of right now. It's not often in geriatric medicine that we get to, I don't know, save lives. We do good work. We recently enrolled a gentleman in our program. He probably was on the autistic spectrum. I think he was labeled as having developmental delay. And then over time, he also acquired a diagnosis of bipolar disorder and was on neuroleptics. He also had worked at one point in the circus with elephants that he was quite proud of. But when he came to us, he came to us because he was failing. And upon enrolling him, it was clear he had advanced Parkinsonism. He was slow, rigid, he had trouble with mobility. And within weeks of joining our program, he was falling and requiring increasing levels of care just for transfers and toileting. So after a fall, he ended up being hospitalized, at which point I took him off of his antipsychotic medication and we discharged him through a skilled nursing facility for rehab. Within, I would say, six weeks or so, his Parkinsonism resolved entirely and he resumed independent mobility. Now, also during that time, his bipolar disorder re-emerged and he became manic. So we saw how that diagnosis was originally achieved, but we were able to treat his mania with mood stabilizers and settled down. And then he was discharged from the skilled nursing facility at a dramatically enhanced level of function and mobility and independence. Now, this is a guy who had been on high dose antipsychotics for years without any medical oversight. Any medical oversight. But through, I think, enrollment and PACE program through, again, interdisciplinary effort here with partners at a nursing facility as well, we were able to restore him to independence. That's beautiful story. How can listeners connect to you? I'm happy to give out my email address and I encourage colleagues from around the country to contact me for any reason at all. So my email address is abur rows@uphams.org. Okay, so we are going into the favorite part of my show, the Rapid Five. So I'll ask you five questions, you answer in one to two sentences. Wow, that's hard. Okay! What failing means to you? I will then have to define what success means, right? I'm sorry. here in my 62nd year, I'm thinking a lot about what is success. Last year, I bought myself an acoustic guitar, and I'd always wanted to play guitar, but I was always afraid to do it. And I was always afraid to do it for fear of failing. But what did failing mean? It didn't mean that I wouldn't become an expert guitar player, because I have no illusions about that. But failing meant that I wouldn't sustain my commitment to it. That I wouldn't pick up my guitar every day and play. That it would sit without being played. So I think failure means, to me anyway, it means that you don't sustain your commitments, that you don't make that effort. You don't show up. You miss 100% of your shots if you don't take it. Right? So attempt! Describe PACE in one sentence. A fully integrated, team based model of care for medically and socially complex older adults. If you had a magic wand, what is the one thing you would change about PACE? I would get us out from the regulatory cloud that envelops us. I would reduce the regulatory burden that consumes so much of our time and energy. Tell us one thing about Adam Burrows that your PACE colleagues might not know. I told you, I'm playing acoustic guitar, but I'm a gym rat. There's no where I'm more comfortable than on a basketball court in a gym or on a schoolyard basketball court. Okay! One message for other PACE medical directors? Stay grounded. Stay in the weeds, in the trenches. Continue to take care of patients. That's what will support you through difficult times and what will sustain your credibility. Well, we are at times. Thank you, Dr. Burrows, for being a guest, and it was a pleasure speaking with you. Thank you, Ankur. Pleasure speaking with you as well. Thank you for joining us for this episode of Keep Up with PACE. We hope that you found the information shared valuable and I invite you to join us for the next episode. Keep Up with PACE is sponsored by CareVention HealthCare, a division of Tabula Rasa HealthCare. CareVention HealthCare provides comprehensive services and solution for PACE organization at every stage. For information about CareVention HealthCare, visit our website at careventionhc.com. See you in the next episode with a new guest. Until then, namaste and goodbye.