Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Stephen Gordon, MD, MBA, Founder and Chief Executive Officer of Edenbridge Health. A board-certified geriatrician with a lifelong passion for improving the care of the elderly, Dr. Gordon founded Edenbridge Health in 2016. He continues to practice geriatrics at Upham’s Corner PACE, is on the faculty of Harvard Medical School, holds clinical appointments at Beth Israel Deaconess Medical Center, Boston Medical Center, and Hebrew SeniorLife, and is a supervising physician for United Community Health Plan.
Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Stephen Gordon, MD, MBA, Founder and Chief Executive Officer of Edenbridge Health. A board-certified geriatrician with a lifelong passion for improving the care of the elderly, Dr. Gordon founded Edenbridge Health in 2016. He continues to practice geriatrics at Upham’s Corner PACE, is on the faculty of Harvard Medical School, holds clinical appointments at Beth Israel Deaconess Medical Center, Boston Medical Center, and Hebrew SeniorLife, and is a supervising physician for United Community Health Plan.
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 to introduce today's guest, Dr. Stephen Gordon. Dr. Gordon is the founder of Edenbridge Health and a board certified geriatrician with a lifelong passion for improving the care of the elderly. He is on the faculty of Harvard Medical School and holds clinical appointments at Beth Israel Deaconess Medical Center, Boston Medical Center and Hebrew Senior Life, where he teaches in the Harvard Multi-Campus Fellowship in Geriatrics. He is a supervising physician for United Community Health Plan, oversees 30 nurse practitioners caring for nursing home patients across the Boston area. Dr. Gordon's career has spanned the worlds of medicine and business. He has been a consultant for the Advisory Board Company, Leapfrog, the Clinton Foundation, the governments of Nigeria, Ukraine, and many other hospitals and health systems. He earned an MBA from the Wharton School of Business at the University of Pennsylvania, where he double majored in health care systems and operations. Subsequently, he attended Yale School of Medicine. He completed his residency in internal medicine at Beth Israel Deaconess Medical Center in Boston, followed by a fellowship in Geriatrics at Harvard Medical School. Namaste Dr. Gordon and welcome to Keep Up with PACE. Thank you so much for having me, Ankur. I really appreciate it. I'm glad you are here. There's always a story behind what we see today. Tell us more about Edenbridge Health. Absolutely. So I've had a lifelong interest in the care of the elderly. Particularly the care of the frail elderly. Really dating back to when I was a kid and had an experience of visiting a great grandparent who had just been put into a nursing home and had instilled in me this lifelong idea that something wasn't quite right about institutionalization and something felt wrong about it and wasn't really sure what I was going to do about it. But went to college. And at the end of college I was realizing I needed to get a job. And I went to the Office of Career Services and I started looking around and I saw this book called Innovations in Elder Care, which was produced by a company called the Advisory Board Company. And actually in it was a profile of PACE. It was a two page spread on PACE, which was not the actual reason, it's just the fact that they put out Innovations in Elder Care was the reason I ended up deciding to go work for them. But that's really how my career got started. I decided I wanted to be a healthcare executive and build better systems of care for the elderly. Maybe a nursing home executive, wasn't sure exactly what, and went to the Advisory Board, started consulting, did that for about four years and was on my way to business school when I was noticing that I started volunteering a lot at a nursing home in Washington, greater Washington area. And I was realizing that to have that kind of impact I really wanted to have, I needed to understand the clinical aspect as well. I needed to understand why it was that this person was suffering with ten different conditions and we can only help them with two or two and a half. And if we started helping them with that third and fourth, it impacted the first and second. And so I actually deferred business school for a year, went back to Harvard, did a postbac and then went to Wharton, got to do Wharton, the kind of traditional way not to joint MD/MBA way. So I had the full two years and was with lots of some of my best friends to this day. And then when they all went to Wall Street, I kept driving and went to New Haven and enrolled in Yale Med School and had the privilege of training at a school with a great history of geriatrics and came back to Harvard and did my residency in internal medicine at Beth Israel and fellowship at the Harvard Multi-Campus Program under with Alan Abrams and Angela Catic. And then I had kind of a career choice in front of me at that point. It was sort of assumed I was going to take an academic position at Hebrew Senior Life and become an academic geriatrician. And I was at AMDA one year and I was having a conversation with a mentor of mine and sort of pointed out to me that I never really what I really cared about was the nursing home patient. It wasn't the nursing home. And that I had known for a long time that the future of the care of the elderly was not going to take place in institutions. And that's really what had drawn me to this in the beginning. And he introduced me to someone who ended up introducing me to one of your previous guests, Adam Burrows. And I ended up taking a job working 50% of my time as a clinical geriatrician at Upham's Corner PACE under the tutelage of Adam Burrows who's been one of my great PACE mentors. And along the way I'd also have the privilege going all the way back to 1998 of meeting a gentleman, Rushika Fernandopulle, who had been an internist who ended up starting a company called IORA Health. Okay. And right around the time I was taking that job at PACE, he had called me up and he said, we're signing a contract with Humana, start getting into Medicare Advantage and we want to start thinking about how we can transition the IORA model, which I had been following along, how they've been developing, how we can translate it into the elderly. And that ended up turning into a 50% job working with them, a venture backed startup company, figuring out how to take really wonderful model of care and adapt it to the elderly. So I had this period of about three years where I was spending half my time at a federally qualified health center owned PACE program run by some really wonderful people, taking care of some very impoverished, very frail elderly people and just really soaking up all that was magical about PACE. And then also spending half of my time at a venture backed firm that kind of had access to a lot of things that the other place didn't. And I sort of had this increasing sense that there was a way that these needed to be combined. And this happened to be right shortly after the legislation. When it was originally passed in 1997, I had a provision to allow for for-profit PACE. And I decided in 2016 to break off and start a company that was going to build a better system of care for the frail, community dwelling senior. And it wasn't actually necessarily going to be PACE. I decided, in fact, for the first three months of the company, you weren't allowed to say the word PACE because we decided we were going to reinvent something even better. And we got a bunch of people around the table and started designing what we thought was the best system of care for the frail, community dwelling seniors. And then we drew it all out and sketched and we started taking it around and took it to some people who we thought could comment on it. And one particularly powerful conversation was with one of the smartest people I know, Alice Bonner. I don't know if you've had the pleasure of talking to her, but she's former Secretary of Elder Affairs from Massachusetts and a nurse practitioner and now works with IHI. And she looked at what we had drawn. She said, looks like you drew a PACE program. And I was like, no, I work at a PACE program. I still had a job at a PACE program. To this day, I'm a practicing PACE geriatrician. I still cover weekends for Adam Burrows at Upham's Corner. And I sort of feel like, no, I'm sure what we did and I kind of thought we asked ourselves the same question the Chinese community in San Francisco asked themselves in the 1970s. We came to the same answer. We need the bricks and mortar center and we need the transportation. We need the deep home health capabilities. Absolutely. Most importantly, we need this really closely integrated, interdisciplinary team. And we need them to not have the burden of insurance approvals. We need them to be able to have global capitation. We need them to be able to make decisions that make sense, common sense. And we need to be able to follow people across the healthcare system. And so we said is let's actually not reinvent the wheel. Let's figure out instead, why hasn't PACE scaled? Why is PACE only serving 55,000 people? Great question. And it was really a very hard question. And at that point I was actually unsure if this was going to be a non-profit or a for-profit. I knew we were going to adopt certain principles that a lot of for-profits were adopting but have a series of challenging conversations to figure out the right way to do this because I had seen what for-profit healthcare, what it was capable of doing and also was it what capable of doing both good and bad and sort of seen both sides of it. And I knew we were going to need a lot of access to capital. And I knew that I did not want to live grant to grant. And I also knew that we didn't really want to take most money from hospitals because hospitals were fundamentally high fixed cost structures, really waiting for heads and beds. And that's just - we need them, they're great partners, but they aren't entirely aligned. So we didn't want to be only dependent on them for money. So we decided that what we want to do is create a mission based for-profit. What we often say is it's a mission first for-profit. Which means we believe that the right care for the frail elderly in the long term is the most cost effective care. But if ever it isn't, we are going to choose to do the right thing for the participant. And in the very long view I was sharing that with Don Berwick a few weeks ago and he mentioned that in the very long view, that actually is the right thing for the company's bottom line too, because you want to be the company that always does the right thing for the participant. And I said that's exactly right. Absolutely. What I did is we said we don't need to be first to market. What we need to do is we need to figure out why PACE hasn't scaled. And I came from the Advisory Board. I was used to writing 100 page, 200 page, 300 page studies and my wife and I decided to fund the company to begin with. And we got a team together and we started going around the country and had about 200 interviews just focusing on what works in PACE, what doesn't work in PACE, and why PACE hasn't scaled. And this is, Stephen, for all that, you went to meet all these interviews to a PACE organization? Well, people in and around PACE, so a lot of actual PACE organizations, a lot of policy people, a lot of experts. We ended up sort of just talking. We have a long list of everyone we've ever talked to. I think we've talked to more than 1,000 people today. Wow. And what we found is it wasn't one thing. It wasn't just the lack of access to capital that was an issue. It wasn't just not necessarily using technology, it wasn't just necessarily state regulations. It was a bunch of things. We came up with a document, which is sort of our only real core piece of intellectual property. I'm excited to hear this! Sometimes I say that the 23 reasons, it's actually now grown to 59 reasons, that PACE hasn't scaled. And what we can do about it that kind of became the pillar of Edenbridge, which was, how do we take PACE, which was not designed to scale, it was designed to take care of a small community and how do we retrofit it to scale. And the answer to us is it's not one thing and it's also not a national solution. It's not a regional solution, it's not a local solution. It's a combination of the three certain things you can do nationally, certain things you can do regionally. And certain things are hyper local because healthcare is fundamentally hyper local. And so that kind of formed the first core of the Edenbridge platform. And then the second thing we did is we started obviously attending PACE conferences and getting known. I think I missed the last one. And I'd been to the 17 PACE conferences, NPA conferences in a row and I missed the most recent and I feel like I broke my trend, but I had an application I couldn't get out of. I'll be there in the fall. But we decided again, we don't need to be first to market. Let's think really hard about what we want this company really to represent what we want this to be about. And we spent a while coming up with a set of core principles, which I'm happy to walk you through if it'll be interesting. Yes, I would love to because that is on my question list because I felt like it's one of the differentiators for you guys. So please go ahead, listeners, to hear that. Okay, yeah, absolutely. I'd love to try to go through them briefly. Every time we're doing introductory phone calls with new organizations, my team tells me how long I have to go through them. But I'll give you the short version. The first one is just a fundamental refocus on personal autonomy. And what that means is just giving people the dignity of taking risks. And that means that if someone makes a decision that we're uncomfortable with, we are the ones who have to figure out how to live with it, not change their mind. If someone wants to continue smoking and we've canceled them and we've documented that if someone is not going to take medications that we think are good for them, we will never ever use - we have a rule that we're never going to use the word noncompliance. Compliance is a property in physics that describes how much a metal curves under pressure. It is not the way you describe a patient. If a patient is not taking the medication that we're prescribing, either we're prescribing the wrong medication for the patient, we're making it hard for them to take, they don't understand why they're taking it, they don't want to solve that problem. It's causing side effects. They think there's a small little dragon in the pill. There's all sorts of different reasons that people don't take medications, but noncompliance is not a term we're ever going to use. We're going to work with people to figure out what are the medications, what is a regimen, etc. And that leads to the second principle, which is a general tenet of geriatrics, really, which is the concept that we want to generally de-medicalize. We want to take long lists of specialists and long lists of medications and long lists of diagnoses, and we want to try to narrow them down to the things that matter most. We talk a lot about the four M's. What matters most for the patient? Exactly what matters with the patient. That's where with one course, sorry to interrupt you there, but I feel like that's where the IDT I always say that we introduced the team to understand that why, right? Like when patient is saying, no, not taking the meds, or they are still continuing to understand that why they are not doing, why they're not taking medicine. It's on us. It's our problem, not their problem. Absolutely. And we cannot write, oh, she's hypertensive because she's noncompliant. No, she's hypertensive and she's not taking the medication we're prescribing, and we need to figure out why. And it could be that she's decided she's at an age where she's not going to take pills anymore, and we might not be comfortable with that, but if she's making that and she's of sound mind, that's an okay decision. We have to learn to respect that. As long as she's of sound mind and she can make that decision and she understands the risks of that, we have to be okay with that. Absolutely. So what will be the message for, let's say, the listener? Because I've seen a lot of time, including myself, getting frustrated a lot of times. We know that Ms. Smith is going to the hospital multiple times because of COPD exacerbation. We did all these things, but she's still smoking, and IDT sometimes get more demoralized that we are trying all these things, and it's still. So what will be your message to all those IDT members and doctors and everybody like me that will get demoralized? Yeah, that's such a good question, and I can't answer it without mentioning definitely my greatest PACE mentor and hero of mine, Adam Burrows, who I still work with. And we have a participant who roughly every three weeks is admitted for a condition that's behavioral related and continues to do this. And we've had to sort of come to terms with it, and we do it in a way where it's hard to describe. It's not demoralizing because we're respecting her wishes. She is living. We're helping her when she wants to stop I mean, I'll just say it's drinking. And we're helping her when she wants to stop drinking as much as we can. And then when she starts drinking again, we are trying our best to help her stop, but at some point, she starts drinking again, and she ends up back in the hospital. And we see her and there's a dignity in just working with her where she is, she is who she is. We're going to try, we're going to make sure that we're supporting her as much as we can. But we're meeting her where she is, and there's something about kind of coming to peace with that and accepting that that actually it doesn't demoralize the team because the team is, yeah, so I think there's a real dignity. It humanizes the patients in a way that makes us feel, I think, better about ourselves because we're taking care of people we're not taking care of, just like, things that we prescribe things for, that we do things for. Anyway I think the general principle of de-medicalization is really important. Our Chief Geriaction, Alan Abrams, who used to run the Harvard Geriatric program, likes to say, "life is what happens in between doctor appointments." And so we are very strict about doing things, very strict about doing things like, these are things that Adam has taught me, but CHF patients do not need to return to clinic every three months. I can adjust, I'm a board certified Internist and Geriatrician, I can adjust their Lasix. If a new medication comes out for heart failure, I might need to call a cardiologist. But I can adjust someone's Lasix. I can manage their heart failure. I can manage chronic conditions. We seek specialists to answer clinical questions, not to manage chronic conditions. And in addition, we do things like when I'm on call and one of our patients is admitted to the hospital, my pager goes off, and I get in my car and I drive down to Boston Medical Center. I sit down next to the emergency room doctor. I open up Epic, and I'm on staff there, and I say I look up, I see the patient, and I say, "hey, this woman, this is her baseline. She's confused at baseline, and she's got bacteria in her urine 365 days of the year. If you check a UA, she's going to be diagnosed with UTI. And by the way, her blood pressure tends to run low, so she's probably going to be diagnosed with urosepsis, and she's going to end up in the ICU. We sent her here because she fell and she's on a blood thinner. She needs a head CT. That head CT is negative". I will write a note in the chart saying, we take full responsibility for this patient. We will have a nurse see her tomorrow, and she is at her baseline, and you do not need to admit her. And the thing is, the emergency room doctors love it because they don't want to admit that patient any more than we want them to. I agree! That's the thing that's so beautiful. That's what's hyper local about it. It's about the beauty of being able to do that. Yeah. And exactly what, Stephen, you mentioned about -we are internists, primary care doctors, geriatricians. We are trained for this. And I remember Dr. Mike Brett, previous PACE medical director, but now with Capstone. Right? Yeah. So I remember when I was the medical director at Inspira and my first visit with him, and he looks at me and he's like, "Ankur, you need to yourself, but you're a geriatrician, so you should know. But teach all your provider that specialists do not pull rabbit out of a hat." There's a lot of things that we can do to manage the CHF and COPD patients, and they don't have to go to specialists every three months. And the specialist is looking at a single organ system. That's true. And not at the whole person. And we are looking at the whole person. We're not just looking at the whole person. We're looking at their whole environment, their social determinants. We're doing their home visits and we're knocking on the walls and see, we're understanding what matters to them. We're understanding their family, we're understanding their history. So that's actually leads to our third principle. Sometimes we get our second and third principle, which is this idea of helping people create a meaningful life. So we've redesigned our intake process to not just be about, okay, what medications are you on and all this different stuff. But how do you get meaning out of your life? And what we found is that most people get meaning out of one of three different things. Not everyone. And Gretchen Alkema, who is also a hero of mine, works at a SCAN Foundation. She once said to me, "the main thing actually we just need to do is get out of the way. We need to make sure the medications, everything we're doing, is not interrupting whatever does matter to someone." And that's sort of the fourth of the getters. But a lot of people get satisfaction with one of three things socialization, spirituality and productivity. And so by socialization, that means that instead of seating people around tables based on who's on a low salt diet or who's on thick and liquids or who's in a wheelchair or whatever, let's sit people around the table based on who they're likely to become friends with. So that when the next wave of the pandemic hits, they're able to actually sustain that social relationship remotely. And they're actually socializing. Let's actually invest in hearing aids and all the technologies. Charlotte Yay is another one of my heroes, and she's obviously a big proponent of everything to do with making sure that hearing technology is available for everyone. Let's overcome. Let's make sure that if someone is spiritual and going to church every Sunday is what provides their life with meaning, that they don't stop going because they're afraid of having an accident. I have a five year old, a seven year old, and a ten year old at home. And not that many years ago, they were all in diapers, and I never blamed any of them for having accidents. I'm not quite sure why we live in a society where we blame elderly people for being incontinent, sphincters get old and stop working. And so let's make sure someone's wearing protective garments. Let's make sure that they continue going to church and don't stop going just because of incontinence. And let's have our vans actually be driving people to church, if that's what matters, for synagogue or mosque or wherever they're going to be able to. Let's actually stop a 97 year old with an A1C of 6.8, from checking finger sticks four times a day and instead let's let her A1C drift up to a more reasonable level. Yeah, I'd say 8-8.5, probably. Yeah! And let's in the afternoon, she can go and she can go read stories to school kids at the local kindergarten if that's what's going to provide meaning to her. And another part of meaning is productivity. You have people who are enrolled in programs who are completely cognitively intact. Yeah. Why not have a former accountant who is cognitively intact do pro bono taxes for a local nonprofit? Why not do things like that? Why not try to, so we really want to design our centers, the way we design our centers is traditionally, we took the pilgrimage to the original On Lok, and we sort of studied it and we studied the architecture, and we worked with Jenny Chin Hanson, a very close advisor of ours, and she had suggested we work with a wonderful woman, Emma Yokota, who's a gerontologic architect. And we started thinking about kind of how you create space and various different things. And one of the things that we try to do is we try to have places where people can do things that matter, that actually create things - either want to have a kitchen that our participants can use to actually cook things if it's safe, a garden, we want to try to have places where people can knit and make clothing. We want to try to have different places where you kind of walk in and you feel like your day is yours. To choose how you want to spend it and be productive, social, spiritual, whatever it is, but have a meaningful life. And the way we sometimes say it is, we actually go a step further. We try to hide, obviously, the clinical components, that's for sure. We don't want the place to feel like a doctor's office. We want anything to feel like a senior center, but we actually want to go a step further. And we actually really want it to feel like a community center. And that's why some of the work that we're doing up here in Boston, actually working with people like Amy Shechtman and 2Life Jewish Communities and Element Care where they're really trying to create incredible ecosystems, multigenerational environments where different generations are able to live together and help each other and everyone is able to give in the way that they can give and take what they need. So that's really the fourth principle, I should say third. The fourth principle is probably the one that's kind of differentiated us the most and that's closely related. But it's this idea that we really don't want PACE programs to be just boxes that are kind of plopped down and feel like they're all the same. And that it's very common for a PACE program to open up. And then the church next door will have a pastor who is helping congregants manage frail elderly people and at the same time complaining about the fact that there are vans parking in front of their driveway because they don't realize that next door is a PACE program, that they could be referred. And then there's people at the PACE program who used to belong to the church who are not going because the two organizations don't know each other. And so what we do is way before the RFP comes out, we start building a community coalition and we start knocking on doors and we start meeting people. And each of our centers is really built around a community coalition that includes all the different entities already involved in the care of the elderly. Yeah, and that's really sort of how we were able to win some of the markets that were really excited about entering in, including Washington DC and West Baltimore. So the community coalition components are really an important part. And to the listeners, I would like to see if you get a chance. You can go to Edenbridge Health's website, it's just Edenbridgehealth.org. And in that section they have a very good section that says that Edenbridge difference. And in that, please go to the"Transforming Communities" and you will see a beautiful picture with all the numbers and what this actually means and what Dr. Gordon is right now talking about. It is beautiful. And Dr. Gordon, I will definitely use some of those pictures and what you have on your website, even for my future presentation that I will be using. Please do. So far for listeners, another thing, if you have noticed what Dr. Gordon has mentioned here is to understand a few things. What matters to the patient and what's the meaning, what's the purpose of our participants? And that's very important to understand in PACE, that what is our participants purpose? And the third point is we talked about the demoralization of the team for them. We are taking care of hundreds and hundreds of participants. Do not drain your energy because some of the patients are not giving you the results that we were expecting. Exactly. Focus on the positive there. So that is absolutely amazing. So tell us right now with Edenbridge, do you consult with the PACE program? So you have now your own PACE program, opening up your own PACE organizations? Great question. So we have been doing this for almost five and a half years and the first two years really just research. We started attending a lot of conferences and talking to a lot of people and then we started building up a team and ended up hiring some of the most experienced PACE operators in the country. And we evolved to the point of being a complete shop. We actually can go all the way from lobbying a seat to pass the state amendment. Participating in that. To doing all the demographic analysis and figuring out everything. To completing the RFP. To picking the real estate. To designing the building. To managing the construction. To passing the state readiness review. To hiring the team. To training the team. Running the actual program. Recruiting the participants. Passing the audit. The whole thing. We're actually a complete stop shop. So what I like to do is we like to partner with organizations in the community and figure out where in those processes they're going to fit in. And in most of our situations we actually have them have a piece of ownership of the actual centers and actually really try to have it be a coalition led group. The first three centers we built, we did build in a different manner. We built them much more as a managed service organization with another company. Where are those three centers? One's in Northern Virginia, one's in Los Angeles, and one's going to be in Bakersfield. Okay. And then the first two real Edenbridge centers that are sort of done in model that I'm discussing are going to be Washington DC, which is opening up in January. The building is complete, the team is half hired and there's beautiful pictures of it. And we're hoping some senators will come and take a look at it. And then we recently were very deeply honored to win the application for West Baltimore and become the second program in Baltimore in 25 years. We've been long fans of ElderPlus - the Hopkins program. We're pretty excited in each of these places. We're just trying to provide the kind of care that's going to make us all feel like this is where we would want our parents to be. This is very exciting and congratulations on this. So with all these things happening, I always think and this is more like a generalized question, not just for Edenbridge Health. Somehow in healthcare there's always a stigma that for-profit companies are here to make money and non for-profit are here to serve. So what do you want to tell the listeners and people who have that stigma that for-profit? I don't know if they're entering PACE, how it will be. What are your thoughts on that? Yeah, so it's great question and it's one I've struggled with a lot. We have mostly raised friends and family, money and mission based capital and have kind of been trying to be very capital light specifically so that we are able to build. I'm a huge believer in social impact investing and I'm a huge believer that you don't need to trade mission for margin, but unfortunately not everybody is. I think society is kind of changing in that direction and starting to realize that but in the long run, if you do the right thing, you're probably going to end up doing pretty well. And that's kind of the belief. I think that there certainly are some for-profits that are a little bit, I think, short sighted and it's not about the quarterly earnings, it's about where we're going to be in the future. But I don't think tax status is equal to whether or not you're a quality program or not. I think that there are nonprofits that do things that I wouldn't consider to be unethical and there are for-profits that do wonderful things. So I think that it's a blurry line and it has a lot to do with the actual people. But it is definitely a real issue in PACE and certainly since for-profits have entered the PACE space, we've seen a dramatic change. NPA conferences used to be everyone was sharing every idea with everyone and now there's sort of a sense of like it's become a little bit more competitive and there's a sense that you have things like intellectual property and stuff like that. It's very hard as a jury attitude. I kind of feel like if I have an idea that I think is going to help an elderly person, it's very hard for me to not share that idea with anyone who could possibly use it to help any other elderly person. I agree. I think Shawn Bloom and Peter and all the folks in NPA are doing a good job at trying to foster an environment in which ideas are really shared and all really rising tide lifts all boats. Sometimes I say, I'm sure each of your guests has probably given a different number of the penetration, how many PACE eligibles could there be in this country? And depending on which of the different borders, the 55 nursing home eligibility or Medicaid depending on 1-2 million even with the current so we're 5% penetration of PACE eligible. I would love to be at the point where we were fighting over that last patient. Let's get there, then we'll box it out. I agree. Let's get there and then we can change. We can box it out, but we got plenty of people to take care of. So I really feel like... I think the pie is big and I feel like everybody can have a piece of a pie in it without stepping on his toes. Exactly. And I agree. And I was talking to one executive in PACE and I was asking him what he thinks about this for-profit and non for-profit. And he actually gave me a very beautiful answer. He's like, everybody is welcome who comes with good intention to help the partner. Exactly. You got to come with good intentions. I think every sector of the health care industry, when for-profits have come in, there's been some changes and a little bit of change in the culture and it takes a little while for things to kind of shake out. But I'm really optimistic that we're going to end up all working together to just have as many people live independent lives in the community as possible. And it really doesn't matter. A nonprofit that's losing money every year can't sustain itself. We have to be able to find a way. I'll tell you, my golden rule is that in the sanctuary of the interdisciplinary team room, it should make absolutely no difference the tax status of the entity owning it. That room is designed as a place where eleven different disciplines get together with eleven different views and eleven different lenses on a person and ideally with a person or with someone representing the person and figure out how to be the shepherd of precious healthcare resources to enable them to live the best life possible. And it should make absolutely no difference whether or not that room is owned is in a building that is owned by a for-profit or non profit. Sure. I want to make sure that our programs are always like that. Yeah, no, I think that's very well said, Stephen, because I'm just thinking my grandma always used to tell me that if you have a difficult or challenging patient, just think about it, that if that patient was your grandmother, what you will do? And she was like, you will find the answer. And trust me, the most challenging time in PACE where actually we are sitting in the IDT meetings and that's what the question I put into the team - if this participant was your loved one, what you will do? And we all come out with an answer. I love that. I love that example. Yeah. And that's what helps do the right thing. So if this participant was your loved one, what you will do? You'll find the answer, go in with the right intention. And I feel like if you do those two things, everything else will follow in line. Especially when we talk about the margins and the bottom line. I think I always tell my IDT, don't even worry about that part. You do what's the right thing to do and everything follows. Exactly. And that's one of the beauty of geriatrics in particular, is that we're taking on people. Most of the people are going to be with us until the end of their life. Correct. And we're not doing things that the payoff is 20 years later. We're doing things where we're avoiding hospitalizations that are a month away or two months away. And so installing that air conditioner, doing the simple things that we always talk about in IDT, being able to do it can have a very immediate payoff. It's also not just about focusing on the problems. One of our principles is also about noticing not just when people are at their worst and we're sort of worried what's wrong with them? Why do they have altered mental status? Let's check their urine and prescribe the antibiotics and maybe we'll get C. diff and end up getting hypovolemic and stand up and fall and break a hip and etc. Let's actually drill down. Let's think really bravely and really think about what's really going on when someone's having a problem. But let's also look at when people are having their best moments. And so if someone is having their best moments, sometimes I'll ask interviewees for Edenbridge, who do they think, giving away our key secret? Like the book, How Do You Build Mount Fuji? The key secret interview, who do you think on the team is the first to know when one of our participants is doing well or doing poorly? And a lot of people say, oh, it's a doctor, because the doctor went to school, the longest doctor. And one of our rules is we only hire doctors who do not sit at the head of the table. Our doctors, our doctors sit at the side of the table. They are one of eleven disciplines and they know actually, I say we're actually the last know. I know by the time that problem hits their kidneys because their creatinine is rising. The first person to know is usually the van driver, because the van driver, the person who knocks on their door, figures out how long it takes them to answer there and then sees them get on and off the van and how hard that is. And that's their stress test. That's a cardiac stress test that they go through every single day. Yeah, let's find the days when someone's doing their best and figure out what's going right. Why did they get a good night's sleep that night? What medicine did we change that's actually allowing them to live a better life right now? And let's actually not just focus on the negative variation. I would say that, Stephen, Adam trained you well because Adam also said the same thing, that your doctor should not be head of the table, you should be sitting on the side with interdisciplinary team members. And he said it this way, that PACE is an anti-hierarchal model. Exactly. That it's not doctors on the top. So I would say definitely. And we want doctors who want that. And I can tell you that. So I love the fact that I will see a patient and they'll have shoulder pain and my shoulder exam, shoulder exams are challenging I might end up getting imaging, I might end up referring, but I can call down and I can have the physical therapist come and actually say, what do you think is going on here? And there's a story I had of a patient where I did exactly that and the physical therapist said this woman had the same problem two years ago and it turned out that her grandson had been born and she was carrying him on the same shoulder all the time. And we solved the problem by having her alternate with shoulder. And by the way, her second grandson was born a week ago. Yes, and so it's the same thing. And so let's just have her alternate which shoulder she's carrying him on and the shoulder pain probably with a little bit of Tylenol, probably go away. And we won't avoid a workup like having that team that you're working with and realizing that you're not special. You're one of the eleven lenses and you're special because you're on that team, but you're not special from the other eleven lenses and that social worker and that occupational therapist and the nutritionist and all the different entities all contributing equally to the understanding of the participants. Going back to now with PACE, and you have done, and the research you have done talking to a lot of people who are associated or working in PACE, what are the things that you feel like that didn't happen in the past decade that now you feel like with you and Edenbridge will do differently moving forward? Well, it's a great question. I really appreciate you asking it. I don't want to say that we'll necessarily think there's a lot of great people in PACE who've tried a lot of great things. And I think that NPA has tried to share a lot of best practices. I think that one thing that the biggest thing is just having more people be able to access PACE in general. And so PACE programs, just generally, there's a lot of reasons for which they don't grow. I think the things that we're going to do differently have a lot to do with the way we work with communities and a lot about the culture, a lot about our intake process, a lot about our use of technology. We're sort of not technophobes. Not technophiles. We don't believe in technology being the solution to everything, but we do believe in using technology appropriately and try to form close relationships with gerontechnology companies that can enhance certain people's lives. But we don't want to create a society where everyone's being taken care of by robots. And a lot of it really comes down to hiring people who I often say the other big mentor in my life is Rushika Fernandopulle, who is the founder of IORA. And I learned a lot of watching IORA and working there. And you hire for heart and you train for skill. So I would much rather hire an occupational therapist who's never worked in geriatrics. Who has the right heart and then train them in Geriatric Occupational therapy, than hire the Geriatric Occupational Therapy who's been doing it for 30 years a nd is tired of it and doesn't really want to keep, you know, and doesn't have the right. So let's hire for heart and train for skill. That is awesome. I'll steal that. And as it turns out, that actually works. Please do! The ability to geriatricize people. Geriatricize. That's one of Alan Abrams great terms. We think that sort of everyone can be geriatricized. We can take people who were working with children and clinicians. You can help them understand, okay, how do these basic clinical principles now translate? And geriatric fellowship is great. And I obviously wish we had more geriatricians. And there's always projections, we need thirty-three however many thousand, we're probably not going to get there. Maybe we will. Hopefully we will. I like the fact that I go to AGS and I know everybody there. Most of the people there took a pay cut to be there. I agree. Most of the people there could have been earning more if they hadn't done a Geriatrics fellowship. That's true. I think the data supports us. I'm not sure, but I think we have the lowest suicide rate of any specialty. I mean, you just go to AGS and you look around and you're like, oftentimes people say, oh, you're a geriatrician that must be so depressing. And I say, no, you don't get it. You don't get it. Pediatric oncology is depressing. Seven year olds being diagnosed with terminal diseases is depressing. I know. Helping a 97 year old live her last years gracefully and die the way she wants to die. Yeah. And tell us that. A lot of people are like, I don't know how you are doing it. Bless your heart. Like, I don't know how you're doing geriatrics. And this is the best example that I give them, actually, for us is that 95 year old patient a lot of time will come and tell me, Dr. Patel, enough is enough. Like, I know I have cancer, I know this will take my life, but these are the five things I want to do before I die. So how can I make that happen? How can I make that happen? And then let's work with them to make it happen. I still do a little bit of work at Hebrew SeniorLife where I cover occasional weekends and I still do a little work. And I had a patient who was 101 and was dying and had three final wishes, and I worked with a family. I had the liberty, because I don't have to make a living as a clinical doctor, had the liberty of working with the family to get their final three wishes done before they died. Awesome. And it was one of those satisfying moments of my life. That is amazing about geriatrics. That a lot of people who tells me, and even to the listeners, if you are considering to going into geriatrics, it's one of the most satisfying job I would say, that I'm doing. And we all enjoy that. And to Dr. Gordon's point, he mentioned they're not enough geriatrician. Yes, there's only 7,000 of us and we need 33,000 of us. So if medical students, you want to go into geriatrics, you're listening to this, feel free to reach out to us. Reach out to me. Reach out to Dr. Gordon because you heard Dr. Gordon talking about mentors, how many times he used the word mentor in this conversation. That has changed and shaped his life. And we all need mentors sometimes. And a lot of mentors have shaped my life. And if you want help to become a geriatrician, feel free to reach out to any of us. Or come to AGS and you'll see a bunch of really happy people just don't go to the dances because geriatricians don't dance very well, actually. Don't go to AMDA dances. The nursing home medical directors are even, quite often like to say. Yeah even in geriatrics we have our own sub-speciality. We think that geriatrician, the PACE, geriatrician are the coolest. Right? The thing about PACE is it is the gold standard. When you take the geriatric boards, if the answer choice includes PACE, you don't have to read the question. It's always the right choice. PACE is the gold standard of care. And the thing is, if we had not built our health care system on basically a broken payment system, if you were on an island and you were going to create a system of care for the frail elderly, you would build a PACE program. It is the exact thing that it is exactly the way to do it. And so it's just there's something about having the freedom of common sense medicine, being able to solve problems, not being able to, just being able to do the right thing and not deal with all of the bureaucracy and the layers and the insurance approvals and all this stuff, it's incredibly liberating. And then to be able to work with a population that is both a combination of complex and also very grateful, very grateful for people who are willing, able to help. So it's a really wonderful profession. I agree. So, Stephen, here we are almost at end of the hour. So before I go to my rapid fire rounds, I have few questions for you, which is how the future of PACE looks to you. I think there's a lot of different ways it can go. I think we're going to see a lot more integration of PACE into senior housing. And I think that there's magical relationships there. We're going to see post-covid PACE, we have gotten over a certain hurdle when it comes to the adoption of technology. We're going to see things like that and then we're going to see variations of PACE and we're going to see PACE reaching out into the community in different ways. We're going to see hopefully, we're going to see PACE. One interesting thing is PACE. When PACE comes to a community it benefits everyone. The hospital, the nursing home. Nursing homes want short term stays, not long term stays. We use short term stays to tune people up and prevent long term stays. Correct. We're going to see, I think, a broader adoption. And then we're going to see, hopefully, regulatory changes that will allow for us to have even more flexibility, continuing to allow primary care physicians to be involved in key decisions, things like that. And then I think eventually we're going to sort of start to see PACE not be labeled just PACE. It's sort of this walled off little garden sometimes and sort of protect it as it is the right answer. And it needs to kind of start growing and integrating into the rest of the healthcare system more broadly. And so I think we're going to start seeing communities that are built around it. I agree. So before we go to our Rapid Fire Round, how can listeners connect to you? Oh, just absolutely come to our website. Our email addresses are all on it. It's edenbridgehealth.org and I'm Stephen@edenbridgehealth.org, and we love talking to people of all sorts. So by all means just contact us. Okay. If you could step into my shoe, what would you ask yourself that I didn't ask you? I will say this to me, one of the things that's magical about PACE is we've seen payers kind of increasingly try to become providers and providers increasingly try to become payers. And that's sort of the managed care and kind of across time we've kind of seen these tights and these mights kind of like grow and never quite meet in the middle. And PACE is the perfect union of the payer and the provider. And I think that that's at the core what makes PACE really different from almost any other part of the health care system. So that would probably be the only thing. Yeah okay, so we'll go into our Rapid Fire Rounds. I'll ask you five questions and you can answer in one to two sentences. I'm worried about this! You got this! What does failing mean to you? You know, I think it meant something different to me before I started this. I think right now, failing is not learning from your mistakes and failing is not recognizing when you're failing fast enough. If you're going to fail, you got to fail fast. You got to move on and you got to not let it make you feel like a failure. You got to realize, you got to learn and move on. Describe PACE in one sentence. The gold standard of care for the frail, community dwelling seniors. It's the most integrated model of care that exists. Awesome. If you had a magic wand, what is the one thing you would change about PACE? I would find a way to open it to the middle class. I think that's the barrier that we really need to work on. I think it's wonderful that we're able to provide really concierge care for people who meet Medicaid requirements, but it would be so nice to be able to provide this level of care for a larger segment of the population. That's a great answer. I'm just thinking possibly I can totally see my father will benefit from that. Yeah. Okay. Tell us one thing about Stephen Gordon that your PACE colleagues might not know. I only have one thing. I'm pretty open, so I have one thing that they might not know they probably do know, and that's when I was like seven, I memorized the first 48 digits of Pi and I still, even though I went to business school medical, I can still recite them and I will online if you want me to, but actually, maybe I won't, because I think that'll be embarrassing. 3.1415926535897932384626433832795028841971693993. Wow! I don't know how it is that gross anatomy didn't take over those neurons, but somehow they didn't. I kind of wish they did, because there's a lot of anatomy that I would be much better off knowing. I've never had a patient where I've needed to know anything more than never needed to know Pi at all, let alone the 46 digits, but yeah! That was awesome. I'm glad to ask you that question. One positive message for our listeners. PACE is hard. PACE is not always fun, but PACE is magical and in the end, PACE produces beautiful results. It produces beautiful results both for the individual, for society, and it's just a foundation to be built on. Don't give up on it just because it's hard to scale. Don't give up on it. Very well said, Stephen. We are at time. Thank you very much for being a guest, and it was a pleasure talking with you. Yeah, it's such a pleasure, and I look forward to seeing you, I hope, at the Fall NPA Conference. Yes. 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@careventionhc.com. See you in the next episode with a new guest. Until then, namaste and goodbye.