Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Shawn Bloom, President and CEO of the National PACE Association (NPA), on the future of PACE. Shawn has served in this role since 2000, is responsible for the strategic direction, operational activities and overall performance of the association, and leads state-related activities. Prior to joining NPA, Shawn was executive director of the Missouri Association of Homes for the Aging and worked in the Policy and Governmental Affairs Department at the American Association of Homes and Services for the Aging.
Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Shawn Bloom, President and CEO of the National PACE Association (NPA), on the future of PACE. Shawn has served in this role since 2000, is responsible for the strategic direction, operational activities and overall performance of the association, and leads state-related activities. Prior to joining NPA, Shawn was executive director of the Missouri Association of Homes for the Aging and worked in the Policy and Governmental Affairs Department at the American Association of Homes and Services for the Aging.
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 very first episode of Keep up with PACE. I am pleased to introduce today's guest Mr. Shawn Bloom, President and CEO of National PACE Association. Shawn has served in this role since 2000. He is responsible for strategic direction, operational activities and overall performance of the association and leads state related activities. Prior to joining National PACE Association, Shawn was executive director of the Missouri Association of Homes for the Aging and worked in the Policy and Government Affairs Department at the American Association of Homes and Service for the Aging. Namaste Shawn, and welcome to the first episode of Keep up with PACE. Thank you. Everyone knows Shawn Bloom as the CEO of National PACE Association. Our listeners would love to learn more about your background and how you got connected to PACE. Well, thank you. I appreciate that question. Actually, my family has been involved in elder care for many years, going back to, I think it was, my great uncle. He was a leader in senior care in the Midwest and in that capacity developed a few kind of what at the time homes for the aging. This is probably 1940s, 1950s, and spent his career working in elder care. And then my uncle, which was his, anyway, my uncle, my mom's brother, was also actively involved in aging care. And unlike many people at the time, he actually went to school for it. A lot of people years ago kind of fell into it. There really wasn't a professional path. It was kind of something you did either as a minister or as some other kind of profession. But my uncle actually went to school, got a graduate degree in long-term care. And the time I was actually just coincidentally working in a nursing home as a CNA. So in college, graduated in pre-med, was destined to go to med school and then kind of got the policy bug, did an internship with my uncle who was managing a healthcare association and spent some time working in state policy and decided that was kind of a little bit more attractive path for me. So I ended up going to graduate school, got a degree in health policy and all the while throughout college and grad school, worked in long- term care facilities. And then after graduating from Grad school, moved to D.C., did an internship in Washington, and fell into the association world and had been there ever since. So it's been a good path. Nice. Wonderful. So tell about more about the National PACE Association, the history of National PACE Association, and what is NPA's role? Yeah. NPA was like a mini trade association developed by a group of people that were interested in coming together and speaking to one voice. Specifically, in 1994, the PACE model of care was just coming out of what was called the replication or demonstration protocol, and in that capacity it started out as On Lok, and then Congress funded a replication. Then they did a demonstration, and then at that point the demonstration came out and said, this thing works. So it was really left to the PACE community to go out and seek authority to become a permanent Medicare benefit as well as a Medicaid option. So they came together in 1994, under the auspices of On Lok and working together, the 13 original PACE programs pursued legislation and eventually in the Balance Budget Act. In 1997, they received authorization as a new Medicare benefit and a Medicaid state plan option. So that was kind of the roots of NPA. I would say over the last 20 or 25 years, NPA has been very much focused on helping to replicate the model in many ways. Our strategic kind of aim is to really kind of expand access to PACE. So in that capacity, we obviously do a lot of the policy work, but we do a lot of I call it kind of nontraditional association work. We are somewhat adjunct operationally to our members, which is pretty unique for a trade association, but it's given us the opportunity to really help to promote good PACE and help our members be operationally, effective and compliant. So our role really is to expand access to PACE, make sure that the brand of PACE remains sound, has a good reputation and help our members grow and do good things in their communities. So that's generally what we do. Talking about expansion, how many current participants are enrolled in PACE today and how many participants were enrolled in PACE when you started as a CEO in 2000? Yeah, that's a good question. Well, today we've got about 134 programs in 31 states. I think our current census is a little bit shy of 60,000, but if you go back to 2000, I think we had 18 programs. I would say the census or total enrollment was probably about two or 3,000, so very small number, and I'm just utterly guessing on that. So I don't have those figures in front of me. That is a great expansion to see. And even the reason or purpose for this podcast is we want to, PACE is one of the best model of care, and we want to see PACE grow. So moving to the little bit of the current situation now that it has been almost two years since we have been in COVID now, or I should say we have been fighting this World War C. Did COVID inhibit or ignite PACE growth? Yeah. I think it depends on what side of the pandemic you ask that question. That's what I often use that response. Going into COVID, we were actively involved in a project called PACE 2.0, where we were exploring ways in which to allow currently operating PACE programs to grow quicker. And really what that meant is over time if you look back our programs were enrolling about, I don't know, three, five, seven what we call net new people each month. As you might know, given the population we serve, the attrition rate, and the death rate in PACE, we lose about 25% to about a third of our enrollees each year. Unfortunately, so for us to maintain census, we have to backfill that as well as add additional individuals. So leading up to the pandemic, we had found that using certain intake and enrollment protocols were able to double net monthly enrollment through our West Coast Collaborative. So we were going at a very good click. But when we hit the pandemic, our enrollment was pretty much static in 2020. We collected all this data and what we found was that essentially our folks were not really able to enroll people during the pandemic. Now that changed in 2021. We are seeing quite an uptick. So I think the short answer is enrollment was flat through the pandemic, but we are seeing a significant surge or uptake in enrollment likely due to interest in non-institutional alternatives. So we're quite encouraged moving forward. Nice. So do we think that our disenrollment during the pandemic was higher? Data does not reflect that. Keep in mind, there's quite a bit of variation from program to program, but if you look in, the aggregate disenrollment was no more or less than it was prior to the pandemic. I also was reading an article about a COVID data demonstrating that PACE model is safer than nursing home care. Tell us more about that. Yeah. We track a lot of data at MPA, and obviously we were interested in what was occurring across our participants during the pandemic with respect to infection and death. We also were receiving a lot of questions. Our members were very curious about how we compared to other models of cure. So we began collecting COVID data for a general 65 and over population as well as the institutionalized population. And what we found is our rates of infection and death are about a third of what they are in nursing homes. So we've been very pleased with that. We actually do believe that in many ways, institutions or long-term care facilities, T he significant death rate you saw is probably more aligned with their environmental design in defense of them. I think it's important to note that a lot of the deaths, I think, were because of the closed environmental nature of nursing homes. B ut we're very pleased, and our folks have done a very good job balancing what I call protecting our participants as well as maintaining the care needs that they have. That is one of a great quality metrics, actually to measure. Ta lking about quality metrics, how is the PACE model of care is better than others because my understanding is the hospital utilization readmissions and a lot of other factors that PACE is doing well compared to other model of care. Tell us more about that. Yeah. I think we went to great lengths to. Immediately when the pandemic began to take shape, we made a very conscious decision that we needed to, for all practical purposes, sequester our folks in their homes and then really redeploy how we organize and deliver services in their homes. And that has really proved to be quite effective. And quite frankly, I think it's really shaped how we think about operating PACE in the future. So I think it's been good. It's taught our folks that they have a lot more flexibility than what they previously understood, and they were forced to do things, I think, that they now find to be quite helpful moving forward. In COVID, and before we move forward to the future. One last question related to COVID, because this is I'm seeing in all industry, either if it's retail manufacturing, somehow everybody is getting more innovative. F or our participants, do you think COVID pushed the envelope on the digital engagement more with our participants? Yeah. I think that's a really good question. Leading up to the pandemic on several occasions, we really encouraged our members to take a closer look at in home technology, whether it be passive or active or whatever the case may be. And I think in some ways in their defense, they were somewhat skeptical, and I think they were somewhat skeptical because they had a lot of trust in their care delivery model. The IDT, the interdisciplinary team in PACE, has proved to be a really important and essential part of the ingredients of what makes PACE work. So I think they had a lot of confidence in what they did. But I think the pandemic forced them to be a little bit more attuned to the use of technology in the home, in particular, through things like GrandPad and other technologies they've adopted. I think they've come to learn that those technologies are not a replacement for the team, but rather a compliment to how they meet the needs of the participants. So I think it's been really helpful, and I think moving forward, you're going to see them be a lot more receptive to technology that comes onto the market, maybe still skeptical, but a little bit more receptive. Yeah. I have always noticed that even if my father is an engineer and he's also always like, the first time I tell him that you should try this, and his first answer is like, no, I'm fine. And I still remember giving him his first iPhone, and he was very reluctant to use it. And he was like, I'm okay with my Motorola. And now he's glued to his iphone that I feel like that I have to take that iPhone away from you. But yes, that I have seen overall, and it's very encouraging to see seniors using technology. And the book I just released Age Is Just a Number. Part of the profits will go to a senior charity. And one of the senior charity I picked is an organization that teaches seniors how to use technology, because if they use technology, it can help seniors be connected to the world, decrease senior loneliness, which is a big problem right now. Especially with increases the risk of depression, anxiety increases the risk of dementia by 50%, stroke by 32%. So I really believe that seniors should be connected to the world. And I hope this pushes forward in more digital engagement. More talking about future of PACE. I'm a big believer that in the midst of chaos, there's always an opportunity. And we have always been talking about new normal. And I feel like, why settle for new normal? We can do new better. So tell me, in this new, better world, what does the future of PACE looks like to you? Yeah, in many ways, I think it's going to accelerate what we had all historically hoped that it would be. And that is if you look historically at PACE, PACE has been a single model of care that has what I call an eligibility boundary around it. You have to be 55 years of age. Nursing home eligible live in this community, and that's fine. But we have not been connected to or adjunct with, so to speak, other service options, in my view. So moving forward, I do see PACE being part of kind of what I call bigger systems. So if you think about it, think about an organization today that sponsors PACE. They've got nursing homes, they may have a hospital, they may have housing, they may have community-based services. We've never really been configured strategically within that mix. We've always been this kind of just stand- alone model of care. Moving forward I see PACE being a lot closer to senior housing. I think the role of senior housing and PACE has always been something that has not been fully appreciated. And I think moving forward, I think to the extent that our country moves away from institutional options, it's the first tip of the spear and moves toward community-based care. You can't ignore the need for housing, good housing options. So I think PACE is going to be closer to housing. I also see PACE as potentially a model of care that may exist in what I call retirement communities. A lot of retirement communities, continuing care, retirement CCRCs. They are designed to allow individuals to really age over time and have available on the campus whatever needs that they might have. And that typically involves senior housing involves assisted living nursing homes, and maybe even in home care. PACE would sit beautifully in that. And it's a very different cohort. 90% of the people we serve, 90 plus percent of the people we serve are duly eligible. The greatest number of people in this country that need long-term care are not, at least at the moment, of need Medicaid eligible. So I think we have a real opportunity to put PACE in different models of care and let it be kind of what I call the care delivery model that exists within that. So I see that. And then lastly, I also see PACE programs understanding that there are individuals that have needs before they become nurse and home eligible. And I've often referred to it as building a pathway to PACE, a service pathway to PACE. What about taking a lot of the competencies within PACE and building them outside of PACE? For example, individuals that may not be nursing home eligible but need a little bit of help at home. They might need a trusted service provider to help them with home modifications, maybe even light ADL care, those types of things. So I think there's a lot of capabilities within PACE that are beneficial to individuals that are not yet nursing home eligible. So as you can imagine, I think PACE could and should fit in a much broader spectrum. So PACE outside wall or something like that? Yeah. Absolutely. So this is very interesting with the senior housing. And yes, I've always seen either if it's a standalone PACE program or with the health system. And this is the interesting point you brought up. So do you see more like housing means there could be a senior housing apartment complex and have the PACE program, or the PACE center just on the first floor? Yeah. We have that today. It's not very abundant. We have several programs that have col located PACE centers within senior housing. It's hard to do from a financing standpoint. And I think it's difficult also for a lot of people to get their head around the fact that not everybody within that senior housing needs to be enrolled in PACE. It stands to reason that individuals that move into senior housing needs change over time. So while they may not be eligible the day they move in a year, two, maybe three years down the road, they might be. And to the extent that they would value PACE, it would be very nearby, and they would still be able to maintain their independence living in their home. But yet have access to PACE where they don't even have to get on a bus. Yeah. And to that, I always think about, like, the health system or standalone who are interested in PACE program. I always wonder me as a geriatrician and one of the success I feel like I was able to get from PACE was communicating and curbside consults from the specialist. Right. They understand that how hard it is to bring one PACE participants to their office, especially with the transportation dressing them up if they are Spanish speaking, sending them a translator with them. So they really have a soft spot for PACE participants. And they were like, hey, if I can help you just with the curbside consult, call me that you don't have to go through all these things. And that always triggered when I was hanging out with my other doctor friends is if I live closer to you, I would love to just help you out. And from that, the conversation came in is do you think, like a group of doctors can possibly get into PACE? Yeah, we have that today. Oh, really? Yeah. We have a group of physicians that are actively sponsoring and developing PACE. Oh, nice. And when we talk about growth and we have been opening up a model of PACE to other people as well, my understanding was always PACE was usually started by non-for profit. Now I have seen for profit sponsoring PACE organizations. How they have impacted PACE organizations now? Yeah, I think the original balance budget did restrict PACE to not for profit organizations. But it set up a demonstration program of for profit that was completed, I think about 2015, and in essence, that evaluation found that there were no kind of material differences between for profit and not for profit PACE. Since then, I think the uptake, so to speak of for profit PACE has been rather slow, but I think that might change moving forward. Unlike other models of care, the incentives in PACE are to provide good care without going into too much depth. I think when you work in a fee for service world, if that's your business model, there are ways to cut corners. I don't think those same incentives exist in PACE. So I think the distinction between what motivates organizations outside of PACE with respect to profit and within PACE are quite different. But I do see significant growth of for profit PACE in the future. As you know, right now, most of our programs that are for profit are privately owned. We have one publicly traded company, and it's going to be interesting to see how different those for profit models are. Sure. I think when you are talking about fee for service, and that the best thing I like about PACE is you can be as innovative as you can. And I always tell a lot of PACE program when the medical directors meet at conferences, especially NPA, we all discuss our success stories. And I always tell about my success story that in PACE, we can be so successful because we don't have to worry about the fee for service world. It's more about doing what's best for the patient. And my success story was one of our participants was going to the ER and has COPD and the nurse educated the patient on how to take the medication correctly. The patient was very compliant with the medication. So what was taking patient to ER and in PACE? And as a geriatrician, we always say that once we can't find an answer, we go to patient's home and do a home visit to see what's going on. And what we found in July, one of the summer months, a patient's air conditioning wasn't working. So now what to do next in a real fee for service world? If I was a geriatrician in the community, I couldn't have done anything for this patient. Now in PACE, I went back to the IDT and asked them for what we can do and IDT recommended - let's get our air conditioning. It cost us few hundred dollars with installation and everything, but we might spend 10, maybe $1,000. But now this patient has zero ER visit since then. That's just an example of one of the success story of how innovative we can be in PACE and the fun of working in PACE and taking care of PACE participants, because I'm not worrying about fee for service. That's one of the beauties of PACE. Not only did it save$200 investment saved multiple thousands of dollars in acute care cost, but more importantly, the participants' health was improved because of that. And yeah, you'd have no ability to do that in a fee for service world. Yes. And talking about success story, Shawn, do you have any success story you would like to share? Yeah. So I think one of the best stories that I've heard that really describes, I think the flexibility as well as the effectiveness of PACE, has to do with a participant who was referred to PACE and was diabetic COPD had obesity, spent most time in a wheelchair, lived in a kind of a Ranch style home by herself with three dogs. Immediately, we did a home visit and realized that the real source of her going to the emergency room was not diabetes was not COPD, was not all the manifestations of obesity, but rather the house was flea ridden, and she kept getting bit, and it was kind of stressing her out and she didn't know what to do. So immediately we flee dip the dogs, we fumigated the house and we avoided Er visits in perpetuity, and she became much more stable. Was much more comfortable in her home, and avoided a lot of excessive costs and excessive visits to the ER that were able to be avoided. So I think that there are many other stories like that, but that's actually a really good one. Yeah. And that's fine. Same thing. If I'm just thinking if that patient was my patient in a fee for service world, I couldn't have helped her because there's only limited things I can do with the resources that I have. And I really believe that PACE is one of the best model of care and the awareness should increase and it should grow. So talking more about growth. And you mentioned about the PACE 2.0. So are we on track with our goal or what's the next move here with PACE 2.0? Do we need to redefine the definition of growth now with the pandemic? Yeah. I think the way that we're approaching it, it's not changing our goal. It may be changing the timeline. As I mentioned, going into the pandemic, we just completed the West Coast Collaborative. We demonstrated that there are ways in which programs could double their monthly enrollment, but we had to kind of put all that on hold as we entered the pandemic. Now that we're coming out of it, we've kind of turned our attention to disseminating those practices. Our thinking before the pandemic because we wanted each program to go through their own kind of discernment about how to do that. But what we've discovered is some really simple things can lead to significantly increased enrollment. So while our goals in terms of census remain the same, I think we're going to push it back a couple of years. Okay. So what was the previous goal? And by what year we wanted to hit that goal? Yeah, our previous goal was by 2023 to hit 100,000 people. This represented exponential growth and PACE. And now I think we're looking at probably maybe a year or two later because we're seeing very significant uptake of growth right now in PACE. Now, what the Omicron was going to do to thwart that in the short run remains to be seen. But so far, I know in many markets we're seeing very significant PACE growth. How can external vendor? Because in PACE, we have a lot of external vendor give services to PACE organization like, let's say, CareVention HealthCare or any other vendors, how they can help PACE grow? Yeah. I think many of the operational necessities of PACE have been satisfied by using outside vendors. I think what that's allowed PACE programs to do is to focus on what I refer to as the core competencies. And that is through the IDT assessment, care planning, service delivery. That's really the essence of PACE. A lot of the stuff that, for example, CareVention, and other vendors offer PACE are things that are more in the back office a little bit. And those back office supports allow PACE programs to really focus on what I call uniqueness of PACE. And that is the care delivery model. So how many patients currently you think estimated qualify for PACE? Because right now we said we are close to 60,000 participants in PACE. But what does the pool look like and how many patients approximately might qualify for PACE today? Well, first off, the vast majority of people that need long-term care right now are not Medicaid eligible. They may become Medicaid eligible as a consequence of paying for their own care fairly quickly. But I think the figure, if I'm not mistaken, is roughly two million. There's about two million individuals that have needs that would probably likely make them long-term care eligible. We are serving a very small fraction, if not a rounding error size number of people compared to those that really could benefit from PACE. So we do have a lot of opportunity to meet the needs of far more individuals in this country. So currently we are at a point that the pool is still bigger and there's an opportunity to do so more participants right now, my understanding with PACE is you need to be 55 years old nursing home eligible. Do you see like that cohort of population expanding. Yeah, I do. You mean in terms of eligibility or the number of people that fit within that eligibility criteria? More like the eligibility criteria changing. I don't. Keep in mind that that eligibility criteria is what states come up with to determine who they're going to fund under Medicaid. So, as you may or may not know, you go across the states that eligibility criteria varies quite a bit. In some states, I live in the state of Virginia, and the criteria is rather stringent, meaning that you have to have a fairly high level of need to be deemed nursing home eligible. And there are other states, typically Northern Midwest states that are a little bit more notorious for allowing to have a little bit lower criteria. So to the point where you have people that may be able to drive themselves to the day center that are enrolled in PACE, that's very rare. But it has happened. I think, to the extent that states are remain concerned about Medicaid spending, I don't see that criteria changing a whole lot. Okay. So would you consider states as one of the barriers to grow PACE? I consider states to be the primary barrier for PACE growth. First off, we are only in 31 states, so obviously 19 states have chosen not to have PACE. That's changing. We are seeing that change quite a bit. But even if they allow for PACE, I think Maryland is a good example. Maryland had one PACE program for 25 years. They capped enrollment at 200 people. That's changed coming out of the pandemic. They've opened up the state. They have an active RFP in process, and they're going to be awarding, I believe, five markets throughout the state. So I think that's an example of what we're beginning to see in the states. But the point is we exist at the pleasure of the states not only in terms of whether we're there, but how widely available we are throughout the state. Secondly, we still have states that cap the budget, meaning that the census is capped. You're in New Jersey. That is not a state that really caps enrollment. But I can cite several states off the top of my head that just every year you have to go in and advocate for an expansion of the PACE budget. And is the reasoning for cap because they think that it's a fixed per member per month that they're giving to the PACE organization to take care of them. And they budgeted for just making up a number of thousand participants, and that's what they will give. Yeah, I think a lot of it comes down to it's much bigger and broader than PACE. A lot of it comes down to the budgeting practices of states. Keep in mind, with the exception of several states like Texas that do every other year budgeting, states are only, they only see the world one year at a time so when you go in and talk to, for example, a Senate budget chair and ask he or she, I'd like to kind of add$20 million to the PACE budget. They see that as new spending, even though we know that it's going to be offsetting to nursing home use or assisted living use or community based waiver use. But then if you tee that up, then typically you'll get a response back from them that says, so you're asking me to take money out of the nursing home budget, then you have a pretty much a political fight on your hands. So it's a very delicate discussion to have. But generally speaking, once you get a budget laid down, then it's a little bit easier moving forward to grow it. Or in the case, for example, in Ohio, we just achieved a degree of success. They used to have their own PACE line item. There was one program, and we convinced the state to allow us to tap into the bigger managed care budget. It's called My Care. So right now, PACE no longer has enrollment caps. We can feed off, as I say, the budget of the My Care, which is really the Medicaid long-term managed care program in the state. We're seeing a lot of changes right now is my point. That are good. That's great. Now, as a doctor, I can say that I understand new revenue and bottom line. And PACE taught me finance very well, which in medical school, we never learned that. And in PACE now finance. And then I was like looking at it. And I would say in the first twelve months, what I learned about finance is actually, don't worry about finance as a doctor. And as you have a great team member, focus on the best quality of care and quality of care is inversely proportional to cost. I had no idea it was just innocently not knowing much about finance. My goal is the best thing is to keep patients outside the hospital. I don't want them to kind of lose their functional and mobility as they are hospitalized, right? Because they're very frail, elderly. And I used to see hospital to rehab to home and muscles is something you use it to lose it. And I don't want our patients...so that was one of the goals that keep them out of the hospital. But focusing on quality of care automatically, the cost goes down. And that's what PACE taught me. So when you go and talk to, like, any states or something, do you show them numbers that hey, this is the regular care. But we are doing the same thing for X amount of percentage less? Yeah. I mean, I often will tell states to the extent that it's true. And it usually is we're about half the cost of a nursing home. Why not allow? So if you take that logic, put it in financial context, we could serve twice as many people for the same amount of money, generally speaking. So, yeah, we do that quite a bit. It is important to note, though, I've heard our members a lot make arguments to states that we keep people out of hospitals, so on and so forth. Not to be crass about it, but states typically, they appreciate that, but it has no impact on a Medicaid budget. They're really interested in keeping people out of a nursing home. Medicare picks up the bill for hospital care. So it's important to really make the right arguments with states. And that typically is how we can not only save dollars, but control cost. Fee for service is very unpredictable, and it really depends on how many people exercise the option to go become eligible and utilize services and PACE to the extent that a person's eligible, you know, at the end of the year, exactly what their costs are going to be, that degree of predictability over time, I become much more appreciative of how that is valued by states. Sure. So when we are talking about barriers and to grow, is there anything that you want to tell our listeners who have potential power to change or remove this barrier? What that will be? You mean a like budget barrier like census barrier? Any barriers to remove in general policies budget. Yeah. I think that's a really good question. I think that's a really good question, because that's the way I think at MPA, we think. What are the barriers to preventing access to PACE, as we think of it? First and foremost, and this has been kind of an observation that's been kicked around by a lot of people in that little pond that we swim in here in D.C. Why is it that nursing homes are a mandatory Medicaid option and PACE is optional? A lot of people in the advocacy community kind of ask that question. The answer is it lies in history. Years ago, we considered and it was true that nursing homes are really probably the most effective way to take care of individuals. The economies of scale that you're afforded in a congregate environment are enormous. But I think we found that there are better ways to do things. So I think you're going to see a lot of movement, especially if the build back better bill passes. There's 150 billion to incentivize states over ten years to really add or expand things like PACE in their states. And so while we may not change what's mandatory and what's optional, I think what you're going to see is you're going to see significant surge of state investment in non-institutional options, which may effectively overshadow the institutional world. And that's good. So that's a big obstacle. The other obstacle, again, is budgeting going into a new state, making an argument about PACE is difficult. Many states are beginning to move toward what's called global budgeting. So rather than have a line item for nursing homes, what I call the tribal line items, the political tribal line items. What about giving the Medicaid director given he or she the authority to have a sum of money? That is pretty much the aggregate of all the line items, but have the ability and the authority to really spend it in the most effective manner possible. And you're beginning to see that take shape a little bit in some states, so that's a big obstacle. The last obstacle is awareness. States can do a much better job at raising awareness of PACE when individuals are deemed eligible. That's not very effective right now. So those are the three big barriers, in my view. Oh, thank you. Now, when it comes to awareness, how can we support NPA's mission? And when we say we it could be listeners, it could be somebody like me, a lot of medical directors who are involved in PACE. Yeah. I think one of the most effective things people can do that want to support PACE is inform people about it. To the extent that people are aware of it and like it, they will seek more information about it. They might even in conversations, advocate for changes. So that's one thing. The other thing is not to ask people to start walking to their state capitals. But I do think the future for us is really going to be focused much more on the state than it has been historically on the federal government. So they can really be a good advocate. They can talk to their elected officials at the state and local level, encourage them to be more aware of PACE and support PACE access. And possibly when we were talking, I was talking to I think, few executive directors during one of the NPA's conference, and they mentioned that awareness also that the state legislators or local politician, they used to invite them to the PACE center and see exactly how PACE center is run, what they do. And they have mentioned that that actually helped them, because now, rather than saying thousand words, they're seeing the picture here. What is PACE and how it works. Yeah, exactly. I mean, so many stories that we've heard over the years that when you see PACE, you love PACE. If you don't really see it, it's a little bit abstract and a lot of people and quite frankly, we've done focus groups over the years. A lot of people will say they kind of get agitated like, don't tell me that that's too good to be true. I think I've seen that a lot by in particular state or elected officials. But if you bring them to the PACE center, it's eye opening. It's hard not to fall in love with PACE if you see it. I agree. And I think one of the requests to the listeners, I think our responsibility is for PACE awareness to grow. And the best way to do that is talk to your friends, family. What is PACE? Invite them to the PACE center and see how PACE center works and what we do, your local politicians. So that is one of the great ways that we can increase the awareness of PACE, and people can firsthand see that how transportation people help our participants go for appointment or take them to Church if they have to. How we have a clinic in the center that the patient is not feeling good, they can get a same day appointment. T he activities that we do, the meals that we provide, and the whole list can go on about that. But I highly encourage everyone to talk about PACE to your friends, family, neighbors in the community. And that is one of the best ways that we can increase the PACE awareness. When we are talking about PACE centers. I always wonder, because we were at a point that we were around 300 participants and the question was always coming up, do we need to expand our center? And now in the new, better world, we kind of realized that, hey, we can be more innovative about the centers, and we don't need to spend millions of dollars with expansion. But possibly we can be more creative in how we can still take care of the patient and do other things. Do you have any idea more like or your vision how the PACE centers will look in future? Yeah. We partnered with an architectural firm about a year ago and basically tried to pose those same questions. What could or should the new day center look like post pandemic? Obviously, a lot of the answers related to improved ventilation, things like that, things that are really much more clinical or those things. But with respect to design, I think we acknowledged that many of our programs became much more comfortable managing care in the community as opposed to in the center. And so a few things. So one I think that the average daily attendance, which used to be 2.5 days a week. I think that's going to be much smaller moving forward, I think that the centers are going to have to be more appealing to a new generation of participants. We are moving from what I call kind of the World War II generation of long term care cohort to a new generation. And as I often say, this is not your grandma's PACE anymore. Many of the individuals that we're seeing enrolling PACE tend to be on the younger side, 55 to 64. It's the fastest growing age segment. These are people that are not necessarily inclined or be motivated to come to day center to play bingo. So I think we need to think about programming a little bit differently. I think we need to think about amenities if we're going to appeal to a non-Medicaid cohort, someone that's willing to pay out of pocket. I think it needs to have much more of a kind of cafe kind of feel to it those type of things. So I think it remained to be seen exactly what that looks like. But I think it's going to be influenced
by:A) our comfort in not organizing all of our care delivery in the center, but taking it in the community, and B) in response to what we think the new cohort will look for and making a service selection. Now, that's a great point that you brought up about changing that, not especially the younger generation or the newer generation in PACE population don't want to come in and play bingo. And I still remember one of the participants actually told me that, Doc, I don't like to play bingo, but I never got an opportunity to learn computer and use the internet. So if you can bring four computers and somebody can teach us how to use a computer and basic things about using internet and browsing, and we did that and they enjoyed it. So that is a great example that we have to be innovative in thinking and cater all of our participants needs. Do you see now, because you mentioned that the average day center attendance of 2.5 days a week may not be there, so participants will be more at home. Do you see any different use of technology in caring for the patient in the home settings? Yeah. We mentioned earlier we discussed earlier in the podcast. I think our folks, as a consequence of the pandemic, were forced to get more comfortable with it. I think it still remains to be seen what type of technology and to what extent they're going to use it. But I think on the PACE provider side, I think we've become a lot more comfortable with it. And also, if you think about the future participant in PACE, these are individuals that are increasingly much more comfortable with technology, if not expecting the use of it. So I think between those that we serve and ourselves, I think you're going to see technology take shape a lot more than it has in the past. I still think it needs to be seen on what that looks like. We talk about passive technology. You can put a weight scale under a mattress. Are we talking about that? Are we talking about video? We talk about medication administration, we talk about robots. What are we talking about? I think that still is an unanswered question. So definitely it's more like that is an area that now we know that PACE participants might be more home. So think outside the box at how we can take care of participants in the home setting. And that is one of the biggest opportunities that we can do. Possibly it could be connection with pads or remote patient monitoring, or medication adherence packages or something like that. Yeah. And I think it will vary based on participant needs as well. Ok. If you could step in my shoes, what would you ask yourself that I didn't ask you? That's a good question. Maybe one thing who will be operating PACE in the future. Maybe that would be. I think that historically, PACE typically gets developed within organizations stemming from a motivated individual. I can think about all the programs at the start of the last 20 years. Typically, there's one individual that has a little bit of a sparkle in their eye. They've seen PACE program and they've read about it. They've learned about it and they get very excited. I think moving forward, you're going to see it happen a lot more at the organizational strategic level. And I'm beginning to see this today where a lot of healthcare organizations are beginning to kind of cast their eyes into the future and think, what is the service that may be appealing in the future not only to policy makers but consumers? And I think it's in my view, it's PACE. So I think you're going to see a lot more diversity in who sponsors PACE. Right now we're seeing a lot of growth of interest among FQHCs. Some of the original PACE programs are sponsored by FQHCs, but we didn't really see a lot of growth in that kind of sponsor. Over the last 20 years, we've seen significant growth among federally qualified health clinics. I also think that you're going to see over time a lot of long-term care providers, most of which have been invested in bricks and mortar institutions, assisted living things like that. I think going back to our comment about where PACE fits, I think you're going to see a lot of these diversified long-term care providers that have senior housing that have retirement communities begin to look at PACE as the care delivery model in lieu of assisted living or nursing homes. Lastly, I think you're going to see PACE become a lot more close to the Green House model. We've got a couple of instances where PACE operates on the same campus with the Green House. It's very symbiotic. It works very well. And we're going to be doing a webinar here pretty soon with the Green House folks, and we're going to be encouraging PACE programs that are in common markets as Green House to really kind of move together and become more close. If we have a PACE program in XYZ market, it's a fairly sizable program. Let's say we got 2030 people in any given day that we're paying for under contract in a nursing home. Why not negotiate with the Green House to develop a new greenhouse within which we would then contract in lieu of your more traditional SNP. So I see a lot of changes taking place, and that could lead to quite a bit of change of who sponsors PACE as well. Great. Just an example for the listener. What is like a Green House PACE look like? Yeah, I think it's just a matter of going to what we talked about earlier. We have a very strong incentive to stay on top of the care needs of individuals, whether they're at home or an institution to the extent that we could dedicate an entire greenhouse to serve just exclusively PACE participants. That provides us a degree of involvement or engagement with those individuals that's far greater than we could do if they were more traditional SNP. So I see that as being appealing. I also think that the culture and philosophy of the Green House is much more aligned with PACE than a traditional skilled nursing facility. So I see them as being very complimentary. So before we go to our rapid fire round, how can our listeners connect with you? Yeah. I think the best thing is to go to our website, which is www.NPAOnline.org that's like Nancy-Paul-Apple-Online .org. Our website is loaded with good information. And if you're a consumer, we also have a consumer website, which is PACE4You. P-A-C-E, the number four, Y-O-U .org, and you'll be able to get a lot more consumer friendly information on that website. Thank you. Great. Okay, Shawn. So we will be in our rapid fire round where I will ask you five questions and you can answer them in one to two sentences. What failing means to you? In the context of PACE, the failure to deliver high quality, good care. Okay. And what feeling means to you in your personal life? Yeah. I think the definition of failure is not learning from your mistakes. We all make them great. Thank you. Describe PACE in one sentence. Common sense, care the way people like it. If you had a magic wand, what is the one thing you will change about PACE? I would make it mandatory as a Medicaid option. What's one thing you wish you had known when you begin your career? Well, that's a good question. One thing I would have known, to be patient. It takes time. Making significant changes takes time and patience. Great. And last question, one positive message for a listener. Yeah. If you're listening and you or a loved one or a friend are anticipating that someday, you, too, might have long-term care needs, you should be encouraged. I think the options that are available in your community are going to get better over time. And to the extent that PACE is part of those options, you'll be fortunate. Thank you. Well, thank you, Shawn, for being our very first guest. It was a pleasure speaking with you and discussing the future of PACE. Thank you for being on our show. Thank you. It's been a pleasure. I really appreciate it. Thank you for joining us for the first episode of Keep up with PACE. We hope 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 solutions for PACE organizations at every stage of PACE. 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.