Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews David Wensel, DO, HMDC, FAAHPM, Chief Medical Officer, Tru Community Care.
In this episode, Dr. Wensel shares how Tru Community Care, one of the original legacy hospices, ventured into PACE and its goals for significant growth in both rural and metropolitan areas. He discusses his experiences and dedication to improving hospice and palliative care services to all patients and families on a national level.
Dr. Wensel is the current chair of the Primary Care Committee and the End of Life and Palliative Medicine Work Group for the National PACE Association. He serves on the board of directors for the National PACE Association, the Governance Committee of the American Academic of Hospice and Palliative Medicine, and the Hospice Medical Director Certification Board.
Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews David Wensel, DO, HMDC, FAAHPM, Chief Medical Officer, Tru Community Care.
In this episode, Dr. Wensel shares how Tru Community Care, one of the original legacy hospices, ventured into PACE and its goals for significant growth in both rural and metropolitan areas. He discusses his experiences and dedication to improving hospice and palliative care services to all patients and families on a national level.
Dr. Wensel is the current chair of the Primary Care Committee and the End of Life and Palliative Medicine Work Group for the National PACE Association. He serves on the board of directors for the National PACE Association, the Governance Committee of the American Academic of Hospice and Palliative Medicine, and the Hospice Medical Director Certification Board.
Hello and namaste, everyone. I am Dr. Ankur Patel, Chief Medical Officer, T abula Rasa HealthCare and the author of the book Age is Just a Number. Welcome to this episode of Keep Up With PACE. I'm pleased to introduce today's guest, Dr. David Wensel. Dr. Wensel is the Chief Medical Officer of Tru Community Care in Colorado. Prior to his current role, he was the Chief Medical Officer of Midland Care. Dr. Wensel graduated medical school at Des Moines University and completed his family medicine residency and hospice and palliative care fellowship from Mercy Medical Center in Iowa. Dr. Wensel is the current chair of the Primary Care Committee for the National PACE Association and serves on the Board of Directors for the National PACE Association. Dr. Wensel is the past Chair of the Membership and Communities Committee for the American Academic of Hospice and Palliative Medicine and currently serves on the Governance Committee. He has also served on the Board of Directors for the Hospice Medical Director Certification Board and will become the President of this board in 2023. To me, he's a great friend, mentor, and an amazing person. Namaste, Dr. Wensel and welcome to Keep Up with PACE. Well, thank you, Ankur, and namaste to you. It is a great honor to be here with you. Thank you so much for asking me to join this. I've been really looking forward to this for a while. It will be a fun conversation, so let's get it started. I love Tru Community's mission statement,"affirming life at every step of your journey with illness and loss". Tell us more about your organization. Yeah, so Tru, in its infancy, has actually been around in the communities we serve for over 40 years. Tru is actually one of the original legacy hospices who was actually involved in the Medicare demonstration project to determine if hospice was a benefit that CMS wanted to allow Medicare beneficiaries to have. I've been very fortunate in my career to have worked at several legacy hospices, and Tru is one of those. That's awesome. And so when I got the opportunity to come here when Michael McHale was the CEO, it was a perfect fit for me in terms of the latter part of my career and all the different services that Tru provides in the communities we serve. So at its core, Tru is and was a legacy hospice. So we serve a large area with our hospice in palliative medicine services. And we have a very growing, thriving PACE program that we're expanding into across the whole Denver metro area now, which is really exciting to me. That is very exciting. So how Tru decided that from this hospice company, we want to get our foot in PACE? Yes. So I helped Midland some with that transition when I started there back in 2009 is when I started working at Midland. They were a very young PACE program. We were the 31st, I think, PACE program in the country at Midland and when I started there, we had a census in our PACE program of about nine or ten people. And so in my tenure there as their Chief Medical Officer, our teams grew that PACE program from ten people to over 500 people, one center to five centers. And so we're doing the same thing here at Tru. Our current census is in the 262-270 range with an expectation that we will grow significantly over the next three to five years. So Tru is one organization who h as PACE and how many centers you have? Currently we have one. Okay. But our intention is to build more as our service areas expanded into multiple other counties and zip code areas now. And we will build centers as the need arises in terms of where we have concentrations of participants that need that service. We're currently serving all of our folks through the center we have in Lafayette, Colorado. Okay. And I should have answered the question that you had of me in terms of how we got into the PACE and I started with the history of Midland. Midland did the same thing because the Medicare Hospice Benefit has been challenged or has challenges around it. Nonprofit hospices who I think want to stay viable and continue providing those services have to look at diversifying their service lines. And PACE was a natural sort of way of doing that. Although, as I'm sure other people have talked about on this podcast, starting a PACE program is time consuming, costly. I mean, there's a lot of challenges around that. Midland was one of the very first hospices that ventured into the PACE sort of space. Now there's several that are originally were hospice and palliative care organizations that have since opened up. But that was the impetus to get us to move in that direction was to keep our hospice and palliative care services viable for the long foreseeable future. So from your experience now with Midland, Tru, and then our previous guest on the podcast, Samira Beckwith, who has Hope Hospice in Florida, right. They are very similar stories. So how from your experience now, especially with the Midland and with Tru, what do you want to say to other hospice companies and why they should consider getting into this? Because the philosophy is very similar. Yeah, it is. And I would encourage any nonprofit hospices, especially the smaller ones, to think about that as a way of being able to sustain their hospice services, because we really don't know currently what's going to come or happen with the Medicare Hospice Benefit. And the reason I say that is because originally when the Medicare Hospice Benefit was determined and set in place, it was carved out of all of the Medicare Advantage programs and other insurance sort of models with CMS, meaning that a person could be enrolled in a Medicare Advantage program and then still access their Medicare Hospice Benefits outside of the Medicare Advantage program. That's going to go away and currently, I think statistically about 50 something percent of Medicare recipients are in a Medicare Advantage program. So eventually all of those services are going to be incorporated into the Medicare Advantage program. In other words, that Medicare Advantage program is going to be required to provide the equivalent of the Medicare Hospice Benefit. Many times they're calling it end of life care or they're giving it some other name because it's not where the Medicare recipient will access the Medicare Hospice Benefit any longer when they are enrolled in a Medicare Advantage program and that's called the carve out. That carve out is going away probably in the next year or two. And so that's going to significantly reduce the number of people who have access to a Medicare Hospice Benefit and would negatively impact smaller nonprofit hospices who don't have some way of sustaining their services over a longer period of time. So that's a great point that you mentioned. So even if like a smaller not for profit hospice who doesn't want to possibly get into PACE, it's still a good idea for them to kind of start working with the PACE organization in a strategic partnership. It is. And I'm encouraging PACE programs to reach out to their local nonprofit hospital to help them to partner with them because those hospice, especially the smaller nonprofit hospices, are going to have to partner with either Medicare Advantage programs or insurance agencies or outside entities. They're going to have to partner with them to sustain their hospice services because if the number of enrollees in Medicare who have access to the traditional Medicare Hospice Benefit really reduces, it's going to significantly impact smaller hospitals. So I encourage them to reach out to PACE programs. And one of the things in my I don't think you mentioned in my bio is I have been the Chair of the End of Life and Palliative Medicine Work Group for the National PACE Association and we developed a significant number of resources for PACE programs that are on the National PACE Association's website to help them navigate some of these issues. Because originally I think smaller nonprofit hospices didn't realize that they could contract with entities like PACE outside the Medicare Hospice Benefit to provide those services. And so it wasn't just me, it was a committee, but I chaired that committee or started it and developed all those resources for PACE programs to help them. Then that also brings another point too, because a lot of time we, all Medical Directors, talk about it. That how we can improve our end of life care better in PACE. And the conversation always comes in as can we do it in house and train our nurses versus let's team up with a local hospice network or program. What are your thoughts on that? Well, if you look at this is another thing I did with Adam Burrows and I edited the last Medical Director's Handbook and I wrote the chapter in that handbook on how to do this. So PACE programs have three options. They can provide all the care themselves that is equivalent to the Medicare Hospice Benefit and essentially they're really required at a minimum to be able to do that, right? Because in PACE, when we have a participant join PACE, that's Medicare CMS does say that the PACE program should provide all the same benefits that that person would have if they were in their usual Medicare. Enrolled in hospice is part of that or end of life care is part of that. So PACE programs can do it all themselves. And I think a lot of PACE programs are doing better at that. When I first started with PACE back in the early 2000s, not many PACE programs understood that very well. Of course, at the time there was only about 30 programs. Now there's 100 and many programs and so they're doing it better, but there's still pieces that are missing. So I always encourage PACE programs who are going to undertake that to really look at the Medicare Hospice Benefit and make sure they're providing all the same levels of service and support that that benefit allows Medicare recipients. So that's one way, okay? The second way is for them to partner with a local hospice and then allow that partnership to grow. And one of the advantages of that is if the PACE program doesn't have people that they employ that have that experience, the hospice can come alongside the PACE program and teach them how to do it. That's a benefit of that. And it also often gives PACE programs access to things like chaplains and bereavement support and that sort of things that many PACE programs don't have. Partnering with a smaller hospice is a great way to do that without a lot of expense because then they can do it on either a per visit basis or they don't have to pay the full daily per diem that the Medicare Hospice Benefit pays. The third way is then if the person enrolls in their Medicare Hospice Benefit, it completely disenrolls them from PACE. And when I started, there were quite a few PACE programs that were doing that. When a person from their PACE program was hospice eligible, they would just simply enroll them in their Medicare Hospice Benefit with a local hospice which disenrolled them from PACE because Medicare won't allow a person to be enrolled in both benefits. And so I started talking about that very early because I think I was one of the very first sort of Medical Directors, Chief Medical Officers in a PACE setting that had a hospice palliative medicine background. And so I was explaining all that to PACE programs and trying to get them to either partner or do the services themselves rather than having the person completely disenrolled from PACE. So those are the only three options that I know of that are currently available to PACE programs. No, that's great. For the listeners - the NPA website they have this great resources that was created by Dr. Wensel and his team. So please look at it. And then also more great other best practices. Also take a look at that. And that's absolutely the third option was something that when we were discussing at my PACE organization, the nurses were like, Dr. P, stop. The third is not an option. We took care of Ms. Smith or our participants for four years. Now when she has two months, we are not just letting her go that way. We will be involved that will comfort the family. So we definitely looked at the first two options, but that was definitely helpful. When we talk about, you mentioned about your current census at 270 and planning to grow. So when we are talking about growth, how is PACE run in Colorado? Is it an assigned zip code? Can another PACE program come into the same zip code or you just are assigned separately? You're talking about something that you know is different in every state. Yes, every single state has a different way of doing this. In Colorado, it is assigned by zip codes. Now, for the first time in the history of PACE programs in Colorado, the state of Colorado is going to allow multiple PACE programs in single zip codes, but you still have to go through the process of application and applying to the state and the CMS to get approval for their zip code. So the state of Colorado came to our program about seven or eight months ago, six or seven months ago and asked us to develop a plan, a tiered plan to move and expand our PACE program into all the zip codes into the Denver metro area. Wow. That was sort of on the quiet for a while. But the state of Colorado announced that about a month ago that they had approved us for move and I think we're going to enroll our first participants in some of those zip codes starting October 1. Congratulations. Yeah, it's a big deal for our PACE program to grow because we were sort of only in Boulder County zip codes, which is north of Denver metro area when we started and up until October 1. So we will enroll our first participants in our PACE program in some of the just north of the Denver metro area. Zip codes is our first tier starting October 1. Oh, nice. And all states again, are different. And when it comes to the support from the state, how is it in Colorado? That's wonderful. Yeah. Our state health department is very supportive of PACE and they see the benefit in terms of really caring for frail elders who are all of them are Medicaid eligible and are often economically poor in areas where they don't have access to healthcare services like they would receive and pay. So the state of Colorado sees that as a great cost savings to them. It's also predictable costs right. That's the only thing that's interesting for states to understand and their Medicaid office understand is this predictable cost. Because PACE is, as far as I know, currently it's one of the only programs in CMS that is at full risk, 100% risk for everything. That's true. So when you talk about assuming risk and Medicare is always looking at these value based models to risk share. Well, PACE is the gold standard. I mean, PACE is the standard that everybody looks at. Now, if anything good, if there's anything good that could have come out of the Covid pandemic it's that the states recognize how beneficial PACE has been in terms of just caring for frail older folks, keeping them healthier, living in the community longer, safely. That one thing alone is enough to make states recognize and CMS to recognize how important PACE can be. In the midst of chaos or covid there's always an opportunity and on the positive side, I'm glad that other states are also looking at the same thing and they have been talking about expanding PACE. I'm very excited for the growth of PACE in Colorado over the next five years to possibly ten years. Do you think the PACE participants will almost double or triple? Oh, easily, yeah. I mean, more than double or triple, I'm sure. And I don't pretend to believe that we will be the only PACE program or that the other program that's serving those areas. There's going to be multiple, I'm sure, and I think many states in large metropolitan geographic areas because if you look at the feasibility studies, there's thousands of participants who could be served, who aren't currently being served. And so I think the potential for PACE expansion in any metropolitan high density area where there's a large population of frail elderly definitely will grow triple. Who knows? I just see it as a way to provide a much needed service in communities where many frail elderly who are poor have no other options. And I think that also in rural part of Colorado, like even the access to healthcare may not be that good that they may not even have a doctor in certain mild radiuses. Right. So part of our approach to this is also serving some of those very rural areas, especially in eastern Colorado, where there is less access and not as much services. It's harder in those settings because the distance is further to travel. But we are doing a lot of innovative things. I think all PACE programs are doing a lot of innovative things with telehealth monitoring, in home support, that sort of stuff that's making a huge difference. And so, yeah, that's another area of concentration for us, is not only moving into metro areas, but actually working to serve many of those rural areas where there's lack of access or fewer services available. That is great. Thank you. Thank you for all you have done in PACE for in mentoring us, a lot of other doctors like me and out there and always speaking at all the conferences, and you have been inspiring a lot of doctors like us. So thank you. I can only say that the thing that inspires me is that so many people that mentored me and helped me and the one thing I always say to any students, residents, fellows, physicians who talk to me and say this all the time, pay it forward. You got to pay it forward. I always pay it forward. So anything that I've been able to do to help others is only because someone helped me and because I could list, the list of physicians and mentors and people are long, long. In fact, some of the guests you've already had on have been mentors of mine, like Adam Burrows and Samira Beckwith, and many people like that. There's many. I don't even want to start down that path because I'll miss them. I won't say them all, but thank you for saying that. I always say I've been very fortunate in my life to do something that I truly love, and I never have felt like I worked a day in my life, ever. David, it's always fun to hear stories from you and Adam and all the Jim Pedulla and talk about, okay, when we were doing this before, it wasn't like this, right. And I will admit, like, I'm spoiled a lot of other Medical Directors. Right now in PACE, we are spoiled. We have all the data in front of us. Quality metrics, financial metrics, the whole Medical Director Handbook. So the foundation, what you have laid before is definitely helping us to build a better building moving forward. So tell us the stories about, like I remember when you were in the Primary Care Committee, there was only, like, two or three doctors. And tell us a story about that. Yeah, when I first started going to the meetings for the National PACE Association and helping with the Primary Care Committee, there was probably only four or five of us that started that at the beginning of that. It's been wonderful to see that grow. And I remember it was very similar to the beginnings of the American Academy of Hospice and Palliative Medicine when I was a fellow back in early in the late 1990s, early 2000s, when HPM was just getting started, we would have meetings that would only be like 9-10 people. Now, the national meetings are much, so much bigger. But when we started, we didn't have all that. We had to start with the Medical Director's Handbook and development of the model practice guidelines and sort of working on how we begin to make it more user friendly and put information in there that is beneficial to newer PACE providers, Medical Directors, whatever you want to call them, because there's different titles in different places, different PACE programs. But it really began with us looking at, okay, so what is the work that we're doing day to day, what are our challenges and how do we begin to develop resources that would be beneficial to PACE programs, medical providers, medical directors, up into including how to supervise and manage other providers. And the biggest thing in the beginning is trying to understand the risk adjustment system and how that unfolds and how PACE is funded and the things you have to sort of pay attention to. So now we have all this data, which is so much better because we can catch things earlier. But in the beginning, it was always like six, eight months later, somebody would go, we're spending too much money on ER visits. I'm like, that was six months ago. We can't fix that now. We have much better, and I have to say too, Ankur, and I don't know how much this is relative to this podcast, but a lot of what we learned was in conjunction with Tabula Rasa, in terms of my working with them on their clinical advisory panel, I think I went to the very first one they ever had. And we always talked about developing resources to help medical providers provide better care. And that's one of the things that always kept me so committed to the work that Tabula Rasa is doing in this space in terms of the research and all of that. So originally there was very few of us. And like you mentioned, Adam, and Dave Wilner and Mike Brett, Jim Pedulla, and Laura, I mean, there's so many. Susan Nelson. I could go on and on these people. Verna Sellers and Gwen, and many of these, and very few of them are left anymore. I think Adam and Jim and I are only three that are left. All those others have retired. And so that core group was so instrumental. And each of us had connections in other places. Like, I know Adam's connected to a lot of other entities, especially with regard to the development of the Rural Ethics Group. And Verna was connected to AMDA and I was connected to HPM. And I think we were all sort of connected to AGS. I remember many years ago at the American Geriatric Society meetings, we started a PACE like, special interest group. And there was a group of only three or four or five of us that did that. I'd given presentations at the American Academy Hospital and annual meetings about PACE many years ago now. But I mean, over the years, we've all talked in our own ways about the PACE, the model, how it started, because it reminds me so much of the beginning of the Medicare has been so much it was born out of a need, and a group of people came together to sort of figure out how to do that. No, I agree. And that's where data helps. Even when I was a Medical Director, even when Tabula Rasa used to host the CAP meetings, I always tried to attend because I learned a lot. And how I used to learn more is because when I was with the health system, PACE was one of my responsibility. But I was also a Medical Director for Population Health and where the health system will serve 50,000 lives there. And that's what I always thought PACE as a minor league, that you learn from it, you nurture your players. In this case, it's more like your programs that work at the PACE level and take it to the major league, which is the Population Health level and that can benefit more. And when Tabula Rasa always used to teach me about their researches and how medication safety helps. And when we talk about risk stratification, again, in Population Health, we used to risk stratify from last year's data and be like, oh, so and so, this year will be sick. Whereas CareKinesis helped me to give that Medwise Risk Score and be like, hey, if you are 25 and above, these are your top patients that will need help and needs to be corrected. So I actually use that a lot and it's all about the data. And I also feel like NPA has done an amazing job with collecting all those data from PACE organization. And even when it was small, the vision was good. So in all episodes somewhere, I like to thank NPA for everything that they are doing and all the listeners. NPA is doing a lot for us if the least we can do is just shoot them an email and say thank you and that will mean a lot to them. And again. Will I be seeing you? October at NPA? No, I'm not going to NPA this year because we have a Medical Director over our PACE services, Dr. Mark Brushon, who's going to be serving in that role. He's going to be getting connected to the Primary Care Committee and doing all of that. And I let the NPA know about a year ago that I would sort of be taking a backseat to him starting in that role and doing that more because that's his position at Tru. So as the Chief Medical Officer, Tru, here, now all the providers from our PACE program, from our hospice program, they report to me, but I'm not doing day to day PACE work like I was when I worked at Midland, because as the Chief Medical Officer at Midland, I was also the PACE Medical Director. Okay, so now from your experience and you have done a lot for PACE, what are the best ways if somebody wants to get involved on all these committees at different level, like the quality primary care, how they can get connected to different committees? All they have to do is shoot an email to the National PACE Association, to Mia Pfeiffer, and she will connect them to any place they want to volunteer because there's much, much need. We need volunteers for the Primary Care Committee, for the Model Practice Guidelines Subcommittee, for the Medical Director's Subcommittee, for the Quality has its own committee, and there's also a research group that works across quality in the Primary Care Committee. People who get involved in planning the educational sessions, they always put out submission deadlines for if you want to present. I mean, there's so many different ways and anybody who might be interested, all they have to do is email NPA or email Mia Pfeiffer at NPA, and they'll get them connected immediately, just as many things as they want to be involved. Yeah, no, that is good because I think your voice matters. So please reach out to NPA. And the best thing is more people we have involved at the different committee, more voice we heard here, and especially with different states, that's also very important because in PACE, all states have different rules and different regulations. So please represent your state at a state level, and please represent your state at a national level. So please reach out to NPA and join I'll shift little gears about it because I'm very proud of you that you will be taking the role as the president at the American Hospice and Palliative Association in 2023. So tell us more about what will be your role there as a president. To do that, I have to tell a little bit of backstory of how I got involved with this. So in early 2000s, late 1990s, early 2000s, when hospice and palliative medicine became a recognized subspecialty in medicine, and by the way, Ankur, it was the first subspecialty to ever be supported by 21 different specialty boards. First time in the history of any medical board being recognized as an actual subspecialty. Hospice and palliative medicine had 21 separate subspecialty boards that supported the creation of the subspecialty of medicine, of hospice and palliative medicine. So at that time, they were allowing mid career and later career providers to grandfather into board certification for hospice and palliative medicine. That stopped in, I think 2011 or 2012. Can I say why 2011? Yeah, go ahead. Because I graduated my family medicine residency in 2011. In 2011-2012, I did geriatric residency and I wanted to give that palliative medicine board exam, but I was not able to. So what we did, and I say we, the American Academy of Hospice and Palliative Medicine did to support mid and later career providers who wanted to do hospice work is they created the Hospice Medical Director's Certification Board. And I was on the original exam committee who wrote test questions for the original certification exam. I did that for five years initially and then rotated onto the Board of Directors for the Hospice Medical Director Certification Board and was Secretary Treasurer for the last two years. And I'm actually going to be named the president of that board in October of this year to serve a two year term. Congratulations. That board is critical to me because many of the places where I've worked, Colorado included, but certainly in Kansas, there's a lot. Of mid career, late career physicians who are doing the Hospice Medical Director's work, who can't stop practicing medicine to do a fellowship year. And so this allows them a way to continue practicing and to just submit life experience as a way of being able to sit for the Hospice Medical Director certification exam. Now, we have many years of data showing the proficiency and it's minimum level of proficiency or minimum level of knowledge in terms of being a Hospice Medical Director. And that was very important to me, serving in rural states, that we provided access to those providers who were doing the work but couldn't do a fellowship. And the American Academy of Hospice Palliative Medicine actually created this board, funded it to begin with and got it started. And so over the years, in all the positions I've served on the American Academy Hospice and Palliative Medicine, it's always been about trying to support rural hospices, smaller hospices, because there's not been a new nonprofit hospice started in the last ten years. Probably, if anything, smaller nonprofit hospices are going out of business faster than any of the others. And so anything we can do to support them. I'll give you a simple example of something we're doing at Tru that's very supportive. There's a smaller hospice in western Kansas that we're supporting and partnering with to keep them viable and going because they're losing their Medical Director. Their services area is over hundreds of miles, and their average daily census is 20 patients or 25. It's not very many. And for them to stay viable and continue working, they need support to help them be able to maintain the level of quality and care and that sort of stuff. So we partner with them to help them do that. Oh, that's great. So before I know you have been involved in this whole hospice and palliative side on the national level, and I remember you telling me a story that a lot of time you went to Washington and you were on the committee, and that panel was called as Death Panel. But we were called the Death Panel. I served on the Public Policy Committee for American Academy Hospice and Palliative Medicine for many years, which just simply meant that we were advocating for hospice things. And by the way, just so your audience hears this, we've been advocating for something called PCHETA for the last five or six years, maybe ten years, Palliative Care, Hospice, Education, and Training Act. We've been going to D.C. And lobbying for that and pushing for that for a long time, which would establish regional Hospice and Medicine Excellence Centers of education. Nice. So we've been doing that for a long time, but that whole story came out of us trying to push for and getting CMS to allow CPT codes for advanced care planning. Right. And it just so happened in the time that was happening, I was in Iowa still as the Chief Medical Officer of Hospice of north Iowa, which is where I did my fellowship program. And actually, at the time we started the Hospice Palliative Medicine Fellowship program there, we were the very first community based fellowship program in the country, and the very first one that was connected to a family medicine residency. All the others were in academic centers, mostly connected to internal medicine residency. And that fellowship program is still there. They have one fellow a year. I served as the first fellow of the program ever when we were building it or developing it, and then stayed on as one of the faculty, as the Chief Medical Officer over all the hospice care services there. But the story is that during that time, Senator Grassley was my senator, and Senator Grassley was really on the forefront of all this hoopla about death panels and death panels unplugging grandma. And one of my visits to Washington, I met with him, and at that time, his medical liaison, Michael Parks. I don't know if Michael is still working in DC. anymore. That was many, many years ago now. So Michael and I and Senator Grassley were in his office in one of their meeting rooms, and I was across the table from Senator Grassley, and I said to him, you know, Senator Grassley, it's really not about whether there are death panels that are going to unplug grandma. What we're trying to determine by doing this is, did grandma want to be plugged in to start with if we can get the advanced care planning codes funded so that we can actually submit them when we have discussions with our patients about their wishes. Because prior to that, it wasn't funded in any way. And it wasn't long after that, I think maybe a year or so after that, the CMS finally released those codes. Although I will tell you, still very few providers use those advanced care planning CPT codes. There's two of them, one for 30 minutes and then one for additional 30 minutes, and very few providers still use them today. Yes. Which is really sad because we should be doing more of that. We don't have to worry about people unplugging our patients or grandmothers or relatives if we know what their wishes were to start with. But you're right. Do you think one of the things that a lot of times the primary care doctors in the community is like, oh, patients don't want to talk and it's too early to talk about those things. And I feel like it's never too early to talk about that. The example I use for that, Ankur, is and I say this all the time when I'm meeting with my patients, I have four kids, and all four of them, I know what their wishes would be should something happen to them, and we talk about it or review it maybe about once a year. My youngest is now 21. But I mean, I did that all through their teenage years, we would just review it as a normal this is a normal thing that we talk about. If something were to happen to you and you can't tell us what you want, your how would you define your quality of life and what you want it to be. And that's what we're talking about. It's not a medical procedure. And the myth is that the physicians believe that patients don't want to talk about it when in fact they really do more than anything else. And I have to give a shout out to my colleague friend, Christian Sinclair in Kansas City, who's at the University of Kansas there. He's the one who coined the phrase "surplus of trust". And so the surplus of trust in medicine is that patients and their families believe that physicians will eventually come to them and say, okay, it's time to stop doing these things. The position surplus of trust is they believe that the patients and families will eventually come to them and say, we don't want to do this anymore. That conversation never takes place. I agree. That's how you put you put it very well, especially the example that you use of your own family. And the reason I'm saying that, and I tell a lot of my patients and their families too, that when you are making decisions at the time when you are not sick, you are making decisions from your mind. That what you really want and don't want. When you are making decisions at the time when you're really sick, you are making decisions from heart and that time you are making more emotional decisions. So it's never too late. I always feel like my thing about advanced care planning is from day one when patient comes in, we need to know what patient wants. I always compare, that is, if I'm driving somewhere from my home, I know where I am going. So from point A to point B, we always either put it in GPS or somewhere we know where we are driving. Why? In healthcare, a lot of times we are driving, our life is running, but we have no idea where we are going. And that is one of the things that I always tell my patients that you need to tell us what you will want so we can respect the wishes. When the family is really stressful, I can sit with your family and tell them this is not about me, it's not about you. This is what mom or dad wanted. So the addition that I would add to that, Ankur, is you cannot do that, and you know this, you can't do that as a primary care provider, outside of the context of relationship with the patient. I know. You have to have a relationship with them where there's trust, right? Because we have way too many people that come into our PACE programs now that have mistrust of the medical system and we have to build trust with them to help them understand that we're not trying to take something away from them or not give them everything that they should have if something would happen to them. It's like you described as the destination. What is the destination going to be and what's that going to look like for each individual patient. And the biggest problem we have today, I think, in fee for service medicine that PACE really cuts across is the time factor. I agree. There's just not enough time in fee for service medicine to do that appropriately. I agree. That's one of the things I love about the PACE model and when I first learned about it, when I was in my fellowship, Hospice Palliative Medicine Fellowship, I was like, that's where I want to practice. I want to practice in that setting because that's truly where the palliative medicine, end of life care experience can be used to help patients and families navigate these difficult conversations in difficult circumstances they sometimes get in. Yeah, that is definitely the benefit of PACE. And to all the listeners, that's the beauty about PACE that me and my providers and my colleagues do not have to see 25 patients in a day. We can see six patients, seven patients in a day, but do an excellent job, spend time with them, build trust with them, and guide them through their journey of their health. So now you're speaking to Tru's Mission statement, right? Yeah! Because you just said it. You just said Tru's mission statement. But that is the beauty about PACE. And one thing I'll say about PACE is even my colleagues who left PACE and are doing something else, even when I talk to them, they still say like, there is nothing like PACE and some of them came back in PACE. And that's good to see from your experience with hospital and palliative medicine. And I think that in the hospital, to our own physician colleagues, we struggle to how do you explain or teach me an elevator's pitch that I can tell my fellow physician the difference between hospice and palliative medicine in 30 seconds. So I can try to do that. The thing that impairs that, Ankur, is most physicians don't understand the Medicare Hospice Benefit. So trying to tell them the difference between the two, if they don't understand the Medicare Hospice Benefit at all, it's really hard. So the way I describe it to them is that hospice is a defined Medicare benefit for people who we believe have about six months or less to live. That's the language and the regulations. Now we can have a little discussion too, about how difficult that is and how bad we are at predicting prognosis, but about six months or less to live. That's the defined Medicare Hospice Benefit. Palliative medicine is really about moving way upstream from that and helping patients, families and caregivers who are struggling with chronic illness and disease. It's sort of that same back to that sort of Tru mission statement in terms of walking alongside them, that journey that they have with chronic illness and disease and meeting them wherever they're at. Excellent. We'll shift gear towards more, we are towards the end of the show now. We'll shift gear. But before we go to the end, all the listeners love stories. Do you have any success or favorite stories of a PACE participant that you would like to share? I have many. I can tell you many stories, success stories of PACE participants. So let's talk about the typical PACE participants so people can know what that is. So on a national level, the average age I think currently of a PACE participant is 74. There's more females than males because females tend to live longer than males currently, although we're making some headway into that now. We're making progress on that. And they on average, have 15 diagnosis or chronic illnesses that we're managing. And they're average taking ten and a half medications a day. And they have a deficit in at least two of their activities of daily living. So many of the people that we have come to our PACE program and I could list off many of them now, they have been caught in a system where they had a primary care provider that they might see once a month or every three or four months. They have a multitude of subspecialists cardiologists, pulmonologists, nephrologists, endocrinologists, I mean, on and on and on. Lots of "ologists". And none of those providers have the opportunity, time or ability to communicate with one another outside of their medical notes. And so many times, many of those frail elders who are living in the community, they're barely living in the community. They end up getting a lot of their care in the emergency department. And so the most vivid memories for me of PACE participants are those who had seven, eight, nine ER visits in the months leading up to enrolling in PACE and then being able to go sometimes one to two years without having to have an ER visit because we were managing them better, providing them support because, you know, most hospitalizations aren't medical, they're psychosocial. Exactly. If we look at the psychosocial determinants of care and help them with their food insecurity, their inability to get medications or be able to take them appropriately, or just their monitoring of their weights and their blood pressure and that sort of stuff, their blood sugar is better. And provide them better support in their homes, try to help them clean their environments better. So many things that PACE does, we provide them transportation to get back and forth to the appointments. We have seen a significant reduction not only in their emergency department visits, but as you know, Ankur, the bigger thing is it actually extends their life. I agree. So they live on average about 30 to 36 months longer than the person, their counterparts, who are living in a nursing home or a skilled nursing facility, not because those facilities are bad. Yeah, right. I always say that because we don't want to be disparaging toward nursing facilities because we have a huge need in our country for that. Yes. It's not because they are bad. It's just because the support we provide them, by keeping them living independent in the community, they do better and their quality of life is better. That's the key, too. We just don't add months to their life, but we add quality months to their life. And we do it cheaper, which is triple aim. Right. We do it cheaper than the average Medicare recipient. Right. That's the only thing that makes Medicare wake up in. That's the reason we want all those positives about PACE to be known so we can grow and more participants can benefit from PACE services and live in community and age successfully with better quality of life. David, we talked a lot of different things. Yeah. One more. If you could step into my shoe, what would you ask yourself that I didn't ask you? Probably what's the similarities between hospice, palliative medicine, and PACE? Sure. And sort of what drew me into that sort of model of care, because the way I describe that to my teams and others is that PACE, if you look at it at its core with the disciplines that are required, and this is the way I describe it, under the Medicare Hospice Benefit, there are eight required disciplines to make up the interdisciplinary team. In PACE, that number is eleven. It's so much more than the Medicare Hospice Benefit. But everything that we do in PACE, including end of life care, is palliative medicine. Everything we do in PACE because most of the people that come to us in our PACE program have a limited life expectancy, often of about two to three years, which is the exact place nationally in medicine where palliative medicine sits. It sits in that space. And so almost everything we do in the space of PACE program is really palliative medicine. And so when I truly got that and I understood that about PACE, that's what really drew me into that kind of care. And one of the things I love about that is being able to develop that relationship with patients and caregivers and families and the team, the interdisciplinary team who is taking care of them, over years rather than weeks. Because even in our hospice program at Tru, which is Tru nationally, about 40% of the patients we serve in our hospice here, we only serve them for two weeks. And so we don't get to build very much of a relationship with them. Sure. So that similarity, when I saw that or that sort of image came to me and I understood that better, that's what really drew me to it with my family medicine background as a primary care provider and hospice and palliative medicine, that's what PACE really is. It's really providing that level of support. So true. Very well said. And how can listeners connect to you? Well, there's lots of ways through Tru Community Care. So trucare.org is our website. I'm also on LinkedIn and those kinds of things. So you can certainly just look my name up on LinkedIn. Connect with me. I'm not much of a social media. Like, I don't post a lot of stuff, that sort of thing. But I'm happy to connect and help others. The one thing I say all the time is you can also connect with me through the National PACE Association and the American Academy Hospice Palliative Medicine and the Hospice Medical Director Certification Board. If I can help in any of those areas or things that I can always help with, please reach out to me. I'm happy to do that because I see it as part of my mission, not just as a medical provider, but providing to continue this type of care. Thank you. So we will be going into the end of the show, what I call the Rapid Fire Round. I will ask you five questions, and you can answer that in one to two sentences. Okay. Ready? Yes. The first one what failing means to you. Failing means to me not trying. Not getting up and trying to make a difference every day in the lives that have been entrusted to us to care for. So not trying. Correct. And failure is not as a normal part of life. Describe PACE in one sentence. PACE is providing care and support to keep frail, elderly, living independent and safely in the community. And if you had a magic wand, what is one thing you would change about PACE? I would change this in a heartbeat and have been working hard over the last ten years to do it. We need CMS to allow us to discount the Part D premium. If CMS would allow us to do what Medicare Advantage programs are with the Part D premium, so many more people could afford PACE. It is the one factor that keeps most people from being able to pay out of pocket for PACE. Okay. Tell us one thing about David Wensel that your PACE colleagues might not know. I am an avid backpacker hiker and mountain climber. You are in the best place. I spend every free moment that I have out in the back country backpacking or hiking or mountain climbing as the primary way to keep myself centered. That is definitely you're in the right place in Colorado. That's why I'm here! One message for other PACE Medical Directors. Yeah. The one message is always get involved. As much as you can get involved with the National PACE Association, the Primary Care Committee, the Medical Directors Committee. There's so much work that needs to be done, and when we come together collectively and work together, it makes us all stronger and it improves our knowledge base. So please get involved. If I could ever encourage you to do that in any possible way that you can. Even in small ways, just serving on some of the subcommittees or helping with any of the educational offerings or any of that. Get involved as much as you can. Well, David, we are at time, but thank you for being a guest and it was a pleasure speaking with you. Same here. Ankur, thank you so much for the opportunity and as always, I'm so appreciative of you and the work you do and the book that you wrote. It's amazing. Thank you for everything that you're putting out in the world to further the cause of caring for frail elderly. 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 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.