Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Maria Zamora, Chief Executive Officer at Center for Elders’ Independence (CEI). Maria has been with CEI since March 2021, and has more than 24 years of experience in the healthcare and insurance industries. Prior to joining CEI, Maria served as Vice President of Senior Care Services/PACE at AltaMed Health Services and Regional Executive Director for InnovAge. She serves as Chair and Executive Committee member of the Board of Directors for National PACE Association (NPA), and serves as Vice Chair and Executive Committee member of the Board of Directors for California PACE Association (CalPACE).
Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Maria Zamora, Chief Executive Officer at Center for Elders’ Independence (CEI). Maria has been with CEI since March 2021, and has more than 24 years of experience in the healthcare and insurance industries. Prior to joining CEI, Maria served as Vice President of Senior Care Services/PACE at AltaMed Health Services and Regional Executive Director for InnovAge. She serves as Chair and Executive Committee member of the Board of Directors for National PACE Association (NPA), and serves as Vice Chair and Executive Committee member of the Board of Directors for California PACE Association (CalPACE).
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 this episode of Keep up with PACE. I'm pleased to introduce today's guest Maria Zamora, Chief Executive Officer of Center of Elders' Independence. Maria has been with CEI since March 2021 and has more than 24 years of experience in the healthcare and insurance industries. Prior to joining CEI, Maria served as Vice President of Senior Care Services PACE as Ultimate Health Services, and Regional Executive Director for InnovAge. She serves as a Chair and Executive Committee Member of the board of directors for National PACE Association and serves as the Vice Chair and Executive Committee member of the board of Directors for California PACE Association. Namaste, Maria, and welcome to this episode of Keep up with PACE. Hello, Dr. Patel, and thank you so much for having me here today. It's a pleasure to be speaking with you and on my favorite topic, which is PACE. Thank you for accepting my invitation. I'm always - for all of the PACE organizations, every time I hear about a PACE organization, I'm always curious to know more about their history, their background, how they started. And especially when I walk into those PACE center doors, I always see ordinary human beings doing extraordinary things. So, please tell me about your PACE center. Absolutely - I'd be happy to. Well, we are remarkably celebrating our 40-year anniversary this year, so I'm very proud to be part of an organization that has such deep and extensive roots in the community. We're located in the East Bay of California. So, we're headquartered in Oakland, but we serve the East Bay and the counties of Alameda and Contra Costa. We started as the Community Adult Day Health Services, so that was the precursor to CEI. In 1982, we opened the first ADHC in Alameda County. And some very wise and visionary community leaders at the time were very closely watching what was happening across the Bay with this remarkable organization called On Lok, who had developed this really innovative model of care called the Programs of All Inclusive Care for the Elderly, or PACE. So, when the opportunity for a replication project came to California - back to California - in 1992, CEI became a PACE organization. And with very humble beginnings, we had a PACE center - it was actually located within a wing of the Highland Hospital - with 40 participants. So, as we fast forward through the years to 40 years later, we now have five PACE centers. We do operate still a CBAS, or adult day health center, and we also operate a Medi-Cal waiver program for home and community-based services. But our PACE centers are really our crown jewel. We've just opened the most recent in May in the city of Concord here in California, and it is growing very nicely. So, it was clear that there was a significant need in that area for these services. So today, through those five centers, we serve about 1,000 participants, and we're continuing to grow. Congratulations on your 40-year anniversary and congratulations on the new center. And the point that one of the things was very interesting - and that's also what I'm always curious about. You mentioned that the first PACE center was in the wing of the hospital. And all the PACE centers have great stories - and I'm telling you because I visited a few PACE centers. One was the old synagogue that was converted into a PACE center. Sometimes, an old grocery store is now converted into a PACE center. And I visited one program, a PACE center in New Jersey, and they had this beautiful glass window. And as a geriatrician, when I walked in, I'm like, oh, wow, this is like good sunlight that comes into the center; my participants can get vitamin D here; and like therapy that reduces depression. And I told the executive director, I'm like, this is great planning.
And she was like:"thank you - but this used to be an old car dealership, and that's why there is all this glass. But we will take that compliment!"Yeah. It's always fun to see the different configurations of PACE centers and hear about the evolution. You can kind of learn a little bit about their history just by looking at their facilities. And here in our headquarters in downtown Oakland, we actually have a PACE day center downstairs. It's our downtown Oakland center. And that portion of the building used to be a bar. And as we were in the process of renovations and converting from a bar, much like a lot of downtown Oakland, there was some graffiti on the concrete wall. And the prior CEO elected to keep that part - and that space is now our rehab gym. And she elected to keep that. And it's really just an incredible nod to the community and a recognition of where we sit and of the past of the building. So, and the evolution of the building - s o that's a lot of fun. That is incredible. This is good. It always reminds you of good history and where things started. That's great. I always wonder, too, about the PACE center. And then PACE is such a small community and not a lot of people know about PACE. So when was the first time you heard about PACE and how did you get connected to PACE? Yeah, I was actually working for a large healthcare delivery system, an acute care system - a multi-campus hospital system in Albuquerque, New Mexico. And we - that system decided to be one of those early pilot or replication projects for PACE. So, that was the first time I heard about PACE - the health system decided to start up a PACE organization demonstration project, and eventually did get full PACE status there. And that was built in a converted skilled nursing facility. So that was reusing that space. But that's where I first learned about PACE. Didn't really work with the program at that time. I was actually on the financial analysis and budgeting side of the house at that time. But things often come full circle. Years later, I found myself with the opportunity to become the executive director of that very program. And walking into that role, I knew I had found my professional home in this model, and I've been here ever since. That is a great story. Did you ever imagine being a CEO one day when you began your career? And tell us more about your journey becoming CEO. Oh, gosh, no. My first role in healthcare - I was in high school, and one of the local hospitals had a summer hire program. So, I started my career in healthcare as a file clerk in the basement of a hospital. And it was the time where they actually were paper files. And we had a little stool where you could roll along the file wall and pull files. We would get archived documents of microfiche, which some of your listeners may not even know what that is. That's where I started in healthcare. And no, did that teenager in the file room ever think that I would be sitting in the CEO seat at an incredible organization like CEI? I didn't think about that. I continued my career in healthcare and continued my education while I was working. I was kind of a non-traditional student. I was on my own at a pretty young age. And, so I worked through my roles in the hospital system and through my education and continued to advance. And, you know, it was a windy path, but here I sit today. Awesome - congratulations. And we all are so proud of you. When we are talking about leadership, I remember when we met last time, we were talking about leadership and talent in PACE. What are your thoughts? Like, how can we grow talent within our PACE organizations? That is a million dollar question. I think that all PACE organizations are really thinking about that today, particularly here in California, where we see a significant growth in PACE. So there's new operators, new types of sponsor organizations, different types of operators that have discovered the secret that we've all known for quite some time- about just this incredible model of care. And so there's competition for talent. And particularly at the leadership level, I think it's really critical that PACE organizations look at ways to grow talent from within. Increasing our bench strength, if you will. I know here at CEI, we're currently looking at ways to use our organizational development director. We just brought on a new OD director, and we're looking at her to help us create these pathways so that we not only have succession planning, but we also are growing internally our PACE leaders. And then creating some content that we can bring people quickly up to speed when they come into PACE. It is an incredibly complex model. I always tell anybody coming into PACE, particularly in a leadership role, give yourself at least six months just to know the right questions to ask. Give yourself a full year before you feel like, okay, I kind of understand how this works, and you will continue to learn every year after that. I continue to learn today. If there's anyone out there that tells you they know everything there is to know about PACE, I would challenge that because it continues to grow and evolve as a model. Yeah - I used to tell my colleagues that I was a PACE medical director for about four and a half years. And after two years, I thought I learned everything. But no, I did not- even after four years, there's something new that you will face in PACE, and it will be another day of learning. Right. Still to this day, I won't ever say I've seen it all, because every time something else that's very interesting arises, I'm like, well, that's a new one to add to the file. Yeah. No, I was talking to another executive director the other day, and it's all about how you grow talent and leadership in your own organization. And to your point, PACE is a complex model, and it takes a lot of time to learn that model. So sometimes grow and empower your own current employees and get them the tools and the education they need, so that they can be the future leader. Right. I think it's always good, too, for an organization to have a blend. Right? Sometimes when you bring in new talent from the outside, you have different perspectives. I think it's critical to kind of look at both sides of the equation and create some solid plans, tools, and training pathways for your internal team to be able to grow into those leadership roles and then sprinkling in some external talent, too. Because although complex, we can train to PACE. What's really critical is the hiring point and getting someone that has those leadership capabilities and has a passion for this model, because I truly believe the people that stay in PACE really love it because it is hard. This is hard work, but it's incredibly rewarding. So, it's identifying the right fits at the point of hire as well. Yes. I always say you need to have a special heart to work in PACE. And Maria, I'm sitting here and talking to you, and it's very inspirational journey from your first job at a hospital filing charts, to becoming a CEO today. And it reminds me of a quote that my wife has in her office, and it's by S heryl Sandberg, and it says, "In the future there will be no female leaders, there will just be leaders." And you are the example of that change. It's very inspirational. So, thank you for that. Well, thank you. And before we go onto your other leadership roles, what advice do you have for the next generation of leaders? Tried or cliche as it might sound, first and foremost, find a mission you connect with, find something you love - that makes the work a whole lot easier. And even when it's not easy, when it's really hard, you can ground yourself in the "why." The reason that you show up every day, the reason that you work really hard. So that's the first thing. The other thing is I would say is don't ever be afraid to take on a new challenge. Don't be afraid to step up. And every role that I've had that I can think of, I never stuck just to the job description. If there was an opportunity for a project or to try something new or a new team, I would raise my hand because I'm one that once I know something, well, I'm looking for something else to do. So, it's part of my nature. But I will say that those opportunities that come to you, the ones that make your palms sweat, the ones that actually make you anxious and maybe even fearful, those are the growth opportunities. So, just don't shy away from those. If you think that there's an opportunity, a project, a role, anything that might you feel like, am I really prepared for this? Have the confidence in yourself to step forward and raise your hand and take the growth opportunity. Otherwise, don't be afraid and believe in yourself. Great advice. Absolutely. Now we'll shift gears towards more your role as - with an organization, or with the association. You currently chair the board of National PACE Association, and you are a member of the executive committee. Tell us more about your role there. Well, you know, the chair of the National PACE Association - I see my role as twofold: one as ensuring representation for PACE organizations across the country, and understanding how the association can best support the PACE organizations. And then I also see my role as supporting that NPA team. Shawn, the CEO, and the leadership team, because as the board, I think that's our role, too, is to support those leaders at NPA so that they can do the good work that will help refine and improve policy and encourage growth and all of the critical things that need to happen in PACE. Sharing the best practices, thinking about education and tools and training so we can grow those future leaders - all of those things that NPA has little components and parts of that really. They have a really robust toolkit that can help, particularly not only new PACE organizations, but there's a lot there for a new PACE organization to lean on. But then they're also helping establish PACE organizations as well. We talk about the complex issues of rate-setting challenges and how they vary from state to state, and Medicare reimbursement for the work that we do and the various versions that we have to adhere to in terms of the risk adjustment scores that we use. But they're heavy lift topics. And what the association, in my view, does that's really critical is bringing all of the PACE organizations together. In reality, if you look at PACE as a service provider in the market, we're still very small. So, I think it's really critical that we have a collective voice with which we speak because there is strength in numbers. That also makes me think about the organization at the state level, which you also serve as a vice chair for the California PACE Association. So, what is CalPACE's role, in general, how do they work together with the national PACE organizations? You know, I think that the state trade association - CalPACE. I'll speak to CalPACE, but all, and NPA, have a very good synergistic working relationship. And CalPACE really tends to focus more on the state issues. So, when we're talking about the rate setting at the California state level - working with the Department of Healthcare Services in California, our Medicaid oversight body. So CalPACE tends to focus more at the state level, where NPA focuses on the federal level, but also is willing to support CalPACE in any advocacy efforts or endeavors that they engage in at the state level. Does that help? Yes, definitely. That helps. So, something that - in last episode, I was talking to Mr. Shawn Bloom, CEO of the National PACE Association. He did mention about National PACE Association doing a West Coast Collaborative. Tell us more about that. Yes. So, the West Coast Collaborative - there was a number of organizations from California, and one from - that has operations in Oregon, Washington, Seattle - that participated in this - it was a growth journey. NPA has developed in collaboration with the Milken Institute, but also leveraging what they call PACE bright spots, or leaders, has developed a growth model for PACE. It's a challenging model, and growth has been very slow for the most part over the past couple of decades. So NPA said, how can we really spur growth? So they looked at organizations that were growing rapidly or had captured a large percentage of market share. And there's this change model, this growth model, that was developed, that's called PACE 2.0. So NPA determined that they would create this learning collaborative, and that was the first one. The evolution was the West Coast Collaborative. So these PACE organizations engaged in this journey to impact growth. And Shawn probably shared some of the metrics with you, but we did see fairly exponential growth at the end of the journey. And many of those PACE organizations, they continue to experience really strong, healthy growth. But really what that collaborative did was leverage the learnings of organizations in a collective. So has that ended, or it still continues? It has ended. There was the initial iteration and then they had kind of a second iteration that transitioned, like everything else, with COVID to more virtual. But that second iteration has ended. Are there any other plans to do something again for growth? I'm not sure at the California level right now. NPA then launched a national learning collaborative. That version, I believe, was entirely virtual because it was launched during - has been launched during the pandemic. So it's - let's take the learnings that were captured from the West Coast Collaborative and now let's see if we can use this even more broadly by having a national collaborative. So, I'm not exactly sure where they are in that process, but I think that they're seeing some of the same outcomes potentially. So, that is always a great effort to see PACE grow - because that was one of the purposes for this podcast - is increased PACE awareness so it can grow. How do you see the future in California about PACE, and the growth of PACE? Well, I really think that California is at the forefront for many reasons. One of the most notable reasons is, like any group of PACE organizations with their regulators, there are times that we don't necessarily agree with what our state regulators are doing. But I do have to say that we have the opportunity here in California that doesn't exist in many states. We do have a really supportive environment for growing PACE and expanding PACE here in California. We don't have caps on our programs, we don't have to petition for slots every year. These are some of the barriers to growth in other states. Our pre-enrollment process that- the approval process that is required at the state level, is very streamlined here in California. We get responses within five days. So these are very different aspects than what you would see in many other states. So, it is a very PACE friendly environment. The number of applications in this last year alone has been really incredible. The Department of Healthcare Services has a tracker on their website, and you just go out there and you just see the number of applications that are in some point of the process. What has also evolved here in California is PACE competition. That is new for the PACE world. We often for many years PACE organizations kind of have their gentleman's agreement, or handshake agreement around - here's my service area, here's your service area. We're seeing a lot of overlapping applications now. When you say overlapping applications - to the listeners, because all states do not have the same rules when it comes to the zip code. So, when you say overlap, before it used to be, you have X amount of zip codes and the other PACE organization has Y numbers of zip codes. But now, they all can get into each other zip code? They can - and have - San Diego was the first place that we saw the biggest impact of this. There's four PACE providers down there, and they all have service areas that overlap each other. So this is something that we're talking to the Department about right now, and trying to define what are they looking at in their analysis to evaluate? Because what we don't ever want to happen is to put at risk an existing PACE organization. Sure. And we want new PACE organizations to have the opportunity to grow. So, you don't want there to be harm with either - you don't want to rob Peter to pay Paul and to the detriment of an organization, or even worse, to participants. So, from where I sit, I think the best - I'm a significant proponent of PACE growth. I do think that we need to be thoughtful in our growth. We should be trying to expand to areas where PACE doesn't exist today, or it's underserved. If there's a current operator that can't expand anymore, then they may need support. So it's evolving in California. It's probably interesting for the rest of the country to watch and see what happens here in the state. Those are great points. And California being on the forefront, not all states have a robust organization as California has. And some states are even starting to just have a small organization. What advice would you give them - who are starting a state organization, or have not started yet, but are in a process to start an organization. Any tips for them? You know, I think that where you have multiple PACE organizations, I think that it's really valuable. So, I would encourage them to continue down that path. Again, it's similar to what I mentioned earlier with the National PACE Association. As a state association, there is power in numbers. Oftentimes when we are trying to promote an advocacy position in California, we do that through CalPACE as the collective. We may be different sponsor types for different tax designations, but where we can come together with one voice to advance policy that's beneficial to PACE, it's really powerful. So, I think that the tip would be to make sure you have all members engaged. You want to have all of the PACE organization voices at the table. Sometimes that can be difficult because you may have two competitors in the room, but, really keeping the focus on what is the policy that will advance PACE. Yes, PACE and participant first. Yes, participant first. That's everything we do, the participants should be at the core. Thank you. This was great information about NPA, Cal PACE - because listeners who are listening all over the country can kind of get ideas on how they can do some new things or how they can work with their state organization. So, we'll now shift gears more towards your center, the current situation - and, before we go to the current situation, we always have to go back 18 months to 24 months. The World War C. What went through your mind in March of 2020 when COVID hit, and what steps were taken? I think it is difficult to put into words what was going through my mind, because I think we were all in a state of confusion. There was a lot of fear, there was a lot of concern, but just that we were in this place of ambiguity, that we didn't really know what this was. We didn't know what to expect. We didn't have clear guidance from public health officials yet. They were changing everyday. Many of us were getting very little sleep. So, it was just kind of an around the clock, on call, fighting the fight one moment at a time situation. We did have to move very rapidly because we cared for the most vulnerable population in general, but particularly to COVID. And so, our most immediate concern in action was decompressing our centers - our PACE centers, which was really heartbreaking because that is the glue of the model. Socialization is such a critical component of health. Absolutely. And it's often overlooked. But we had to do the right - to keep our participants as safe as possible. And our staff, we had to bring in a large volume of laptops that we didn't have and get them deployed to team members. We had to create team check-in protocols to ensure that we were still connected to our participants. You know, being a former PACE medical director, this is a very high-touch model of care. And so we had to think about, okay, how do we make those contacts now? How do we ensure that it's great that they're in their home bubble and safe, but how do we monitor their healthcare and ensure that we're not missing something there? We retooled our medication delivery process. We created activity kits so that we could engage participants in their homes and activities as time evolved, we did - we started doing Zoom activities. Kind of a fun thing about that, or a positive, unintended benefit there was, it started to break down the center walls because the Zoom activity could include participants from every center. So, they started to meet, virtually, the people that they never would have met before. So, delivering meals to homes since we weren't serving them in the center. So, we just had to kind of take a look at everything we provided within the PACE center and think about how can we now move that out into the home. Absolutely. This always reminds me, and more like in the PACE world, what we go through, a lot of people outside of the PACE world would not understand that. And to all the listeners, I would like to personally - me, my team, the entire CareVention HealthCare team, would like to thank you for how you handled the COVID situation. You were on the frontline with not much information at that time - in the early March and April of 2020. You hung in there and took care of our participants. So, thank you. Well, thank you, too. I just think that something you touched on just now pointing many of our listeners may not know what PACE is. I want to thank you for this podcast. Any way to raise PACE awareness, I think is so critical. But I also want to thank you for, you know, in your book, you talk about the PACE model of care. You do such a nice job outlining various options for older adults, various care options. But, you actually talk about PACE, and we haven't seen that in so long. And the other thing that I thought was really beautiful is you devote a section to caregivers. Because in our view, PACE is a team-based model of care. That team includes the participant at the core and the center. That's why we call them participants, r ight? But those family caregivers are such a valuable member of the team that I just really appreciate you both bringing some attention to PACE as the model, and then to the critical role of caregivers. Thank you. I'm very honored and humbled that you enjoyed my book, and the point about caregivers - because I always feel that healthy caregivers equals to healthy patients, and in our case, healthy caregivers equals to healthy participants. And the caregiver plays a very important role, and to participants' well-being. But on that side, in my book, I was also trying to more put a point across that as much as we care for our participants and our participants' caregiver, we always have to remember, too, that our employees are also - or might be somebody's caregiver. And one of the message from the book, I want to reach out to everybody, and especially if you are in a position to help your employee who is a caregiver, please allow that flexibility and think outside the box to make the policies that help your employees. They might be your best employee, but remember, they are also a daughter or a son, mother or a father, and brother or a sister. At some point, we all will be caregivers, so we should all strive for empathy and understanding. That is such an excellent point. And many of them are caregiving on both ends. So, maybe they're caring for their adult parent and they're also caring for a child. Yes. Or young adult. I really appreciate that point. And if I could, I have a story about - this is one of the great things of PACE is that, it really doesn't just impact the individual. It's impactful to a whole family and to communities - we hire from the community. There's just always this ripple effect of this beautiful model of care. But I do have one story that kind of speaks to the participant and caregiver dynamic. We had a participant who was a little bit on the younger age, had a traumatic brain injury, and this, as a physician, you know, the change in a person that they undergo with that type of injury. So, she almost felt to her family from one day to the next, became a different person. Someone who was very vibrant and liked to get out and about and do things. And she could not do for herself anymore. So, she was frustrated, t he family was frustrated. The husband had to work. The only caregiver available was her young adult daughter who could not go to college because she had to be her mother's caregiver. They heard about PACE and they came into the center to visit, and she was an amazing caregiver. This young woman, she was so protective of her mother that she was a little hesitant about leaving her in the center. So she came and attended with her for a few days at first u ntil she had a comfort level. She saw that her mother was doing well. She started to see the changes in her mother's affect and her personality in a positive way. When she would come home at the end of a center day, she gained enough trust and confidence in us that she re-enrolled in college. She was starting to engage with her friends again. And, the really remarkable thing is just the physical appearance of both women. When they first came, they just were tired, disheveled. They kind of had been in sweats. And, as time went on, she re-enrolled in class. Both of the women, they came in and their hair was done, their makeup was done, they were dressed. It's an outward appearance, but we present outwardly what we're feeling internally, oftentimes, and we just saw this transformation in both the mother and her caregiver daughter with the support of PACE. That is an absolutely beautiful, beautiful story. I have goosebumps right now, and thank you for sharing that story. And this is the purpose - these kind of stories needs to be heard nationwide. So that people really understand how PACE can make a difference in, not only participants' lives, but also a caregiver and a family member's life. And that's the beauty about PACE that - every day I feel like, oh, my God, my day is such a chaotic, busy day. But when I was driving home, I had that sense of satisfaction that we as a team helped a participant, or their family member today. And that is the beauty of PACE. So, with all this COVID, and I always think that victory comes from finding opportunities in a problem. So what are the top one to two things that you feel like their opportunity was created in your organization, and you might make some change for better? I said at one point that COVID was the opportunity that none of us wanted. And I truly believe that because I think what COVID taught us, particularly as PACE organizations, who, when you have a long- standing model of care that is surrounded or umbrellaed under a lot of heavy regulatory requirements, it can often feel like, well, we can't really make any changes. We just need to just kind of stick to the script and keep moving forward. I think what COVID taught all of us is we can be incredibly flexible, we can be innovative, and we can still do so within the constructs of our regulations. We learned to broaden our points of delivery, to really think about what else could we do in the home? We learned how to leverage technology in a different way. We initiated a program called Web Links, and it's an iPad training program. And as the participants graduate from the program, they are given an iPad. We were awarded some grant funding, and had planned this before COVID, and they were supposed to be large classes in person. So then, just like everything else, the team here, the IT and activities team had to pivot and say, okay, how do we deliver this content virtually to people? I mean, we're trying to train them how to use the device. How do we train them on how to use the device on the device? So they did a really incredible job pivoting this training. We worked with a local entity that does this type of training to secure the trainers, and it still exists today. And some of the really beautiful stories that have come out of this - we had one participant who said that she had a sister in the hospital. And now, of course, during COVID, she couldn't visit her. And her sister was really declining even more because she was just very depressed, having a hard time recovering. With the iPad, she was able to FaceTime with her sister, and that made such a significant difference for both women. We had another participant who has been on the verge of being unhoused for many years. We do a graduation ceremony, and so I saw him after and I congratulated him - I ran into him in the center. Mr. X, congratulations on graduating from the Web Links program. And he said to me, "I've never really finished anything in my life - so it was meaningful to me that I finished this program and that you had the celebration for us." And he said, "I love this place. I told my center director that I would sleep in the broom closet here if I could because I don't ever want to leave PACE." So we were able to leverage technology and just really think about how do you deliver care outside of the center, both inside and outside. Do you see in future - now staying on the technology side - what other kind of technology do you see coming in PACE? Do you see more like remote patient monitoring, medication adherence machines? Absolutely. I think our greatest opportunity is how can we create a SNF at home? Not completely. We're not going to replicate every service. But what tools and technology can we put in the home around monitoring and safety, so that we really can deliver on that promise of PACE, which is allowing that senior stay in their home for as long as they desire up until they pass, they transition. So, I think that technology can go a long way there. I think we got to get more creative. It's not, you know, remote patient monitoring has been around for a long time, but what's the enhancement of that beyond just a scale? And what else could we put in the home? What kind of sensors, what kind of video? Who do we connect it to? Can we have a centralized hub that monitors them remotely? Yes. And then staff that can respond quickly? I don't know. I think there's just a lot of opportunity. The sky is the limit. I agree. And I think you just raised a point that we can make our listeners think that all of our innovators in PACE, there's an opportunity here that we normally use the PACE centers for more socialization, and the day-to-day care the participant needs - what else we can do in participants' home to keep them safe, monitor them safely, and do whatever we can at home, versus sending them to the hospital? So, now fast-forwarding PACE, and to the current situation. Do you feel like - how is your employees' morale? Because COVID has burned out a lot of the healthcare employees, and anything else you or your PACE organization has done to bring them all up? I'll be incredibly candid here. It's tough. Our teams are just tired. They're just tired. They are so passionate and they care a lot. We talked about it earlier - you have to have a special kind of heart to work in PACE, and I believe they do. But even those with a special heart get tired. Compounding that, even in addition to all of the challenges and stress and uncertainty around COVID, we're all now facing a significant staffing shortage. It is hard to find team members to hire. And we, like many PACE organizations, have grown, so we need to add additional team members. And that's a struggle. And when you have a vacancy in your center, or two or three or whatever, however many, those that are there have to pick up the burden. Correct. So, we've done a lot - we've tried to really look at our benefits package. What enhancements could we add from that perspective? We continuously evaluate our pay ranges because we want to pay fairly. We live in one of the most expensive areas of the country, so we want to make sure that we're paying fairly. We're competing with big health systems here, so that's tough. So just that doing everything we can to bring more resources into the organization - letting our teams know, look, this is not - we're not holding on anything. We're bringing as much resources as we can. We are using a lot of different tactics to try and bolster our hiring and our position and just our awareness. That awareness piece impacts hiring, too. So we're trying to do a better job telling our story of why CEI is such a great place to work, why PACE is a great place to work. Are you a clinician who would actually like to get to know the people that you serve? We don't have panels of 2,500 participants or patients here. It's very small and it's a very personalized care. So just telling our story. But we have looked at the benefits too, and just little things like offering a bilingual pay differential. We just put that into place over the last year because we have an incredibly diverse population here at CEI of participants. Sure. So, just anywhere that we can kind of show up how we support our employees. We're trying to do that. Yeah. Do you see any new work structure like hybrid model, or work from home opportunities for non-clinical folks? We're really evaluating that right now. We're kind of engaging in an analysis and looking at all our positions to determine are there some that could be hybrid? So we're kind of going through that exercise. In our centers, it's challenging because our participants do come in, so we have people to serve. So, there are many roles and PACE that really can't be a remote role. And even hybrid can be challenging because we want to make sure we have enough people to serve our participants while they're with us. But we are looking at that. Talking about participants now coming to the center, do you see the average days in a week that participants used to come before COVID, and after COVID, has changed? Somewhat. I mean, there are some participants that I think have elected to - they want to step back a little bit. Another thing is we do have some participants that are still hesitant about coming in. We had others that were just chomping at the bit. They were so excited to come be with their friends again and their team and to see their social worker and to see their favorite GA in the center. But there's still a few that are somewhat hesitant and have a preference to primarily stick to the medical appointments and rehab appointments. But little by little, I think people are wanting to get out of the shell. Now, once again, we have a new variant, so we're monitoring very closely. We're learning to just kind of roll with this tide. And that's where it comes. Everything is so new, and everyday is evolving, and it's a new challenge that comes in. So, the best way we always deal with it is make the best decision that you can for the amount of information you have at that particular time. Absolutely. That's about the best we can do. Yeah. With the participants, did you face challenges with getting your participants vaccinated? We've been quite successful in terms of the first series that we did. We were at 93% with our participants. Wow. That's amazing. So, we did very, very well. Our staff - we're in California, so 100% of our staff is vaccinated. And now we're working on the boosters. So, we're going through the process. I think we're at about 62% boosted right now, but it could be more now because we have pop-up clinics constantly, but we've actually done - yeah, there's still some that, to this day, on the participant side, have held out. But, by and large, we've been very successful and very proud of my team. They did an incredible job in communication, in planning, and in deployment. Thank you for doing that. That is amazing numbers - 93% of the participants that time, and 100% of the employees, because I'm also hearing from other PACE organizations that actually, they also struggle getting their employees - convincing their employees to get vaccinated. Well, again, we're in California so that we had a state mandate that healthcare workers be vaccinated. So, now we have just been issued another mandate for the booster. So, we're preparing to comply with that deadline as well. Have you noticed - because when COVID started, our enrollment team can't go out and market our program as much as they would like to. So, I assume that at time the growth might have staggered or declined. But, how do you see your enrollment and your census now? That is very true. Many PACE organizations, at least as a component of their marketing strategy, use a very grassroots, boots on the ground approach with their sales and sales and marketing teams. There was a little bit of a slowdown at the beginning, but just like everything else, creates creativity in the team members. And, how can we connect with people? How do we continue to grow enrollment? And we've actually seen really strong growth over the last year here at CEI. So, I'm really proud of that team. They've thought of different ways to connect. Also, our marketing communications team has thought of creative ways around digital marketing and other things, other ways to raise awareness and get the word out and drive those referrals to CEI. So, referral wise, do you think we are back to pre-COVID, or better, or same? You know, it's hard to say without doing a really deep-dive in the data because we have employed some new tactics. Sure. So, I don't know if we could look by each type of effort and see, okay, was that one? Is that the same? Is it better, is it worse? But I think that we're doing very well, and we're just trying to keep the momentum, and also being mindful of the staffing challenges. Our goal is always to deliver high quality care in a manner that the participants are highly satisfied. So, we're always kind of monitoring both sides of that equation as well. And how can our listener, and external PACE vendors like CareVention HealthCare, or other vendors, help PACE grow? I think there are a number of ways. I mean, you've taken on a very direct way in helping and you've created this podcast, you've written this book that highlights PACE, as well as other care models. But, I think that from the vendor perspective, creating the services that they offer, if they are best in breed of their best practice, if they can create efficiencies with the service provision, that's going to really help PACE. It gives the team members who are there today more capacity, and the ability to focus on the participant care, which is what they really want to do, rather than a bunch of administrative work. So, I think where vendors can have processes that are lean and efficient and actually assist the PACE programs, and becoming more efficient, and giving those IDT members - or excuse me, interdisciplinary team members - capacity to serve the participants. I think that's one way. I also think there's opportunities through the state and National PACE associations. Sometimes there's advocacy efforts. I think the vendors can lend their voices there, too, and help promote policy that supports the expansion and growth of PACE and also protects the integrity of the PACE model. So before we go to the favorite part of my podcast, which is the rapid-fire round, I have two more questions. How can the listener connect to you? So, the listener can connect to me - w e have our website, which is CEI. Elders.org, and they can find out a lot of information about our organization, but they can also get a sense of our leadership team and connect with us. And if they want just more information around the PACE model itself, there's opportunities to request for information. And we're always happy to provide information, to provide tours, to answer any questions that people might have about CEI, or I'm always happy to answer questions about PACE. Your listeners can also follow us on Facebook. We do have a CEI Facebook page, Center for Elders' Independence. And then we're on LinkedIn as well. Thank you. Then we can move to my favorite part of the podcast, the rapid-fire round. So, I will ask you five questions, and you can answer in one to two sentences. Okay. What does failing means to you? Opportunity for growth. I think that failing is - failure is an incredible teacher. If we let it be such, I think that we should try new things. Fail fast, pick yourself up, move on, and try again. That's how we learn and create incredible new innovations and opportunities. Great. Describe PACE in one sentence. PACE is a compassionate, holistic, fully integrated model of care for the most vulnerable members of our society, our frail seniors. If you had a magic wand, what is the one thing you would change about PACE? Okay, I'm going to go off script here and give you two things, because it's my magic wand. I would increase PACE awareness nationally, and I would remove the barriers to PACE growth. Awesome. That was your one, so you can use it. Who inspired you, and why? So, I'm going to go with my first inspiration, and that was my mother. We lost her at far too young an age, but she had such an impact on everyone whose life she touched. She was the epitome of quiet strength and grace, and she was never loud or in the forefront, but she always had a way of advocating for those around her. And, if there was a position to be held or someone to be protected, she was fierce, and, in just a very beautiful way. That's very inspirational. And, I bet she's looking at you, Maria, and she's proud of you. Thank you. One positive message for our listeners. One positive message for our listeners. I'm going to go with a positive message that has emerged out of a really negative situation in the last couple of years. Is - I think there has been a spotlight that has shown on PACE, on the PACE model of care. We have demonstrated that we've been able to keep this very vulnerable population safe and cared for and connected during a time of a lot of uncertainty, and a lot of disconnection, and a lot of isolation - and we've tried to do our best to limit all of that for our participants and I think that we're finally getting noticed for the incredible work that these PACE teams and PACE organizations do day in and day out. Great message. Well, we are at time. Thank you, Maria, for being our guest. It was a pleasure speaking with you. Thank you so much. I really enjoyed myself and it was a pleasure speaking with you as well. Thank you for all you're doing. Thank you for joining us for this episode of Keep up with PACE. We hope that you found the information shared valuable, and I invite you to join us for the next episode. Keep up with PACE is sponsored by CareVention HealthCare, a division of Tabula Rasa HealthCare. CareVention HealthCare provides comprehensive services and solutions for PACE organizations 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.