Keep Up With PACE S1E5 | Army Colonel (Ret.) Ross Colt, Medical Director at Gary and Mary West PACE

Host Ankur Patel, MD, MBA, FAAFP, interviews Army Colonel (Ret.) Ross Colt, MD, MBA, FAAFP. Dr. Colt has served as the Medical Director for the Gary and Mary West PACE since 2018 and is a family physician with more than two decades of clinical practice experience, including a deep background in academic medicine and leadership in managed care environments. A decorated war veteran, Dr. Colt served two combat tours in Iraq and retired after 24 years as an Army Colonel.

Transcript

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Hello and namaste, everyone. I am Dr. Ankur Patel, Chief Medical Officer, Tabula Rasa HealthCare, and the author of the book Age Is Just a Number. Welcome to the episode of Keep up with PACE. I'm pleased and honored to introduce today's guest, Dr. Ross Colt. Dr. Colt serves as the Medical Director for Gary and Mary West PACE. Dr. Colt received his undergraduate degree at the University of California, Davis, his medical degree from Dartmouth Medical School, and his Masters of Business Administration from Pacific Lutheran University. He is a family physician with more than two decades of full spectrum clinical practice experience, including a deep background in academic medicine and leadership in managed care environment at the regional and national level. A decorated war veteran, Dr. Colt served two combat tours in Iraq and retired 24 years as an Army Colonel. Namaste. Dr. Colt, thank you for your service and welcome to Keep up with PACE. Thank you, Dr. Patel. It's an honor and a pleasure to join you here. Thank you. When I was doing my research on Gary and Mary West PACE, it reminded me of a quote from Winston Churchill, "we make a living by what we get; we make a life by what we give." There's always a story behind the PACE organization, and my understanding is your organization is all about giving. Please tell me more about your organization. Absolutely. I think that's a wonderful quote from Winston Churchill. And I would just share that ethos, if you will, that it's an honor to serve. Gary and Mary West PACE has been in the business of providing critical clinical care to a group of fragile, vulnerable seniors. And these seniors are precious and irreplaceable human beings. And the mission of Gary and Mary West PACE is to allow them to age at their home for as long as humanly and safely possible. You may be aware that Gary and Mary West themselves are philanthropists that have had a lot of impact on the senior community, not only in San Diego or California, but nationwide, through some efforts with the West Health Foundation, both on research grants, such as supporting a geriatric emergency room program here in San Diego and nationwide, and working with policy makers to help lower the cost of prescription medicines. So, Gary and Mary West PACE is just one of the more recent projects that the Gary and Mary West Foundation have helped assist. And so, our doors opened back in 2019. We sort of started the clinic and the day center from the ground up in about July of 2019 and welcomed our first participants in September of 2019. And then we've been rapidly growing since then. And, so now we're up to just over 200 participants, I think about 211 at last count. And, we are learning as we go. But, it truly is, to come back to my first point, it is an honor to serve these vulnerable seniors. Very nice. And, what a mission. And, I was just thinking when you were saying about also having an institution for policy makers in Washington. And that itself, right? We talk about change, but real change you have to have a proactive approach, and talk to the lawmakers, and help to make that change. So, thank you for that. Also, I noticed that the foundation was in senior care before PACE, and they have done a lot of great work with the senior community. What was the specific trigger for Gary and Mary West to be like, let's get into PACE. Great question, Dr. Patel. I think that Gary and Mary West have always embraced innovation and let's be on the cutting edge of technology. What are ways that we can better help seniors? And, so PACE as an organization, and as a concept, is something that is rapidly growing. Many of you may be aware that PACE first started about 50 years ago nearly in the Bay Area. A little tiny clinic known as On Lok. And, they had a mission back then saying, you know what? We would like to be able to serve seniors in their home and allow them to stay at home for as long as safely and humanly possible. And that mission has not changed at all over time. But PACE as a concept, PACE as a philosophy, and as a movement, has grown dramatically over time. I think at last count, we're over 140 PACE programs across the United States, they are coming alive in many different States. California has I think maybe more than 15 different PACE programs. And, even here locally in San Diego, we have new PACE programs that are sprouting up. I like to think that the way the PACE is going would be almost like if you are a coffee fan and you backed up, say to around 1992, 1994, you went to this little coffee shop in Seattle and you said, you know, these guys really haven't done what is this place called, Starbucks? I think that this might take off. And so, that's where I think we are with PACE. I think we are going to continue to expand to meet that desperate need that is out there for the silvering community that we have in the US. That is a great example that you are using. And, now we are up to a point with Starbucks. Like, rather than saying I want coffee, I want my Bucks. And, I hope that we get to that point with healthcare that they will be, hey, let's join a PACE organization. Absolutely. I think one of the beautiful things about PACE is it helps align incentives by trying to avoid unnecessary emergency room visits, by trying to avoid unnecessary hospitalizations. You align the wants, dreams, and desires of that individual human being because they don't want to go to the emergency room unnecessarily, and their family doesn't want them to go to the emergency room. And, honestly, society at large doesn't want them to go to the emergency room unnecessarily just because of the tremendous costs that are invoked. And so, PACE organizations are committed to helping work with wraparound care, all inclusive services for our vulnerable seniors to avoid those unnecessary ED visits and unnecessary hospitalizations. So, talking about that, currently you started in 2019. So, in this two, two and a half years, your growth is amazing that you are at 200 plus participants now. Any future plans to grow within the current PACE center or add more PACE locations? I would say to those questions, yes and yes. We are very blessed that thanks to the philanthropy of Gary and Mary West, we have a beautiful state of the art center here in San Marcos with a focus on healing. For those of you that are able to visit the building, or even, there's a virtual tour on our website. It is a lot about light. It is a lot about beauty. It is a lot about healing. And, so here in our center, we are at 200 right now. We would love to see our numbers double for this center to get up to 400 participants, maybe even 500 participants. But, since we have embraced the concept of PACE, we don't want to stop there. We are looking at potentially expanding to other satellite sites, whether here locally, in San Diego or beyond, because it's estimated when you look out across our nation, that again, in silvering in their age, there's probably more than 90% of the demand for PACE that is yet unmet. I think there's a tremendous opportunity to serve all of our vulnerable seniors by further expanding PACE.

I wish you luck for your growth, and I cannot wait to come and visit your center there. And, especially, I really admire your mission. It reminds me of a sanskrit word that my grandma used to always say: 9:10

"seva", s-e-v-a. "Service", and a simple desire to help others. Absolutely. And that's the beautiful mission that you carry. I will shift the gear more now from your organization to more towards you. And, you have an interesting background, and there is nothing nobler than risking your life for our country. Tell us more about why you decided to join the military. Yeah. So, early on, back in the day, the military represented a way for me to attend college. My family did not have a lot of money, and, I did not want to take out hundreds of thousands of dollars in loans. And so, in addition to being a patriot serving our country, it found a way for me to go to college. And, then similarly, once I finished college, there was an opportunity to have another scholarship for medical school. And, even down the road a bit later, another scholarship for business school. And so, the military has been very good to me. And, it's truly been an honor to serve my country for nearly a quarter century. I never thought I would stay in the military as long as I did. But, I had a beautiful and wonderful set of opportunities to provide excellent care to my patients. Now, a lot of people would assume if you're a military physician, that you're mainly taking care of young, healthy folks. But, the majority of the care that I provided as a military family physician was to the elderly, to dependents - I did a lot of obstetrical care, delivering babies, and to children. So, I really got to do full spectrum family medicine in the military. And, then, when I hung up my spurs in 2018, if you will, I had always just had a soft spot in my heart for the older population. I always thought it was such an honor to serve somebody that had walked the earth for seven decades, eight decades, nine decades, and be able to talk to them and listen to their stories and just gain the tremendous wisdom that they had. And so, I continued my service, but in a slightly different way as a Medical Director for PACE. And so, it was a wonderful transition, and, I think I've been very blessed in my career. Thank you again for your service. Tell us about the journey - you went twice to Iraq during your term? I did. And, how was that when you were there caring for the patients? Yeah. So, that was a fascinating journey, as you mentioned. And again, an honor to serve my country at war. The two deployments I had were both very different. The first deployment I had from 2003 to 2004 was as the squadron surgeon for the first of the 14th Cavalry Regiment. I deployed with the stryker brigade. This was the first time the stryker vehicles were ever used in a combat environment. So, I was with the cavalry. Now, for those of you that aren't super familiar with military history, you're probably more familiar with the infantry. So, the infantry is the front line soldiers. So, that's the forward edge of the battle area. And then, the cavalry, that I was with, actually go out in front of the infantry. They are the scouts, so they're driving around. It used to be, back in days of yore, they would ride horses. Now, our horses are kevlar-armored SUVs with beltfed grenade launchers, and M60 machine guns, and Mark 9's, and things like that. So, I lived out of vehicles for many months, traveling around with the cavalry, providing medical support to the cavalry regiment. Doing things like advanced trauma life support, providing both routine medical care, and as you might imagine, trauma medical care on the battlefield. So, I became very accustomed to providing medicine in a very austere environment where really I was probably the senior medical authority for a 30 to 40 miles radius on the American side. So, that was a very clarifying experience, one that I carry memories with me, both good and bad. But, it's caused me - there's a lot of things I don't take for granted anymore. Taking a hot shower, walking barefoot on carpet, being safe, and not having people shooting at you are all good things. Yeah. Being grateful. Thank you for that lesson. Now, you retired, and now from a military doctor to becoming a geriatrician. Yes. How was that journey for you? Yeah, no, great question. So, as you might imagine, it was a transition. Now, throughout my career, even as I moved up and rank into positions of greater authority, and a lot of policy, I always kept up clinical. I never gave up the clinical mission. So, I was always seeing patients. And, seeing an 80 year old in a military hospital is not all that different than seeing an 80 year old in a civilian clinic. Believe it or not, they're both humans, and they both have medical problems. They both have concerns. One of the unique challenges of PACE is also one of the honors of PACE is that we are able to serve the underserved. So, 90% of the participants we serve are dual Medicare and Medicaid, which here in California is Medi-Cal. And, so many times these people that we have the honor of serving have the social determinants of health that are sort of stacked against them. So, most of the people we serve have no transportation resources, no car, no bus, no motorcycle, no bicycle. We provide their transportation to and from. Many of the participants that we have the honor of serving have no family members that live locally. And many of them actually are very socially isolated. So, we provide a lot of their social support through a variety of different methods. And, we have all these different disciplines with a shared vision of allowing them to age at home. So, we have physical therapists, social workers, nurses, recreational therapists, dietician, primary care providers. There are just all these people with a shared vision of supporting these precious, irreplaceable human beings to allow them to thrive at home for as long as possible. So, how did you end up like, oh, let me join a PACE organization? Did you even know what was a PACE organization, and how did you find PACE? What resonated with me about PACE is the model, because the model just makes sense. Again, as I researched it, I found that alignment between the wants, dreams, and desires of both the individual human being, that patient that we care for, we call them participants because they participate in their care. But, I just thought it so made sense that if we can find the most fragile, the most vulnerable, the most medically complex, and then wrap a loving, supportive, compassionate team around them, that seemed like the best way to attack this problem, if you will - to take a military term. We are not having a team of eleven people work on a 20 year old healthy tennis player. This is an 80 year old that's on twelve different medications that's in and out of the hospital. And so, by providing that entire team to support them, that's what makes a difference. That's how we're able to have an impact. And, oftentimes I realize that the medical piece of it is often not the largest piece of it. Many times it is our social workers, many times it is our transportation drivers that are addressing the patient's needs. So, managing their congestive heart failure, while important in its own regard, may not be the most important thing to them.

Yeah. And, I think that's the beauty about PACE, that we address the social determinants of health, which nationwide, everybody else is struggling. People do not realize that actually transportation is a big issue. Housing is a big issue, and we try in PACE to figure it out. And, that's where our IDT is an amazing - which is interdisciplinary team to our listeners. And, I always used to call them the miracle workers, and especially the social worker, and I'm like so-and-so doesn't have a place to go. And somehow they come up with an answer by evening: 17:58

oh, I found an apartment, and they can go here. And, I'm like, wow. No, I fully agree. Shout out to all our social workers, that, I agree with you, are miracle workers many time with our participants. They do an amazing job day in and day out, providing excellent care for our participants. But, I think you hit upon a key thing in the social determinants of health that many people do not understand. It's very easy for me as a physician to say, I've got somebody with brittle diabetes, and I'm increasing their insulin. I'll say, why don't you increase your insulin by four units in the morning, four units in the evening? And this sweet, friendly 80-year old woman is looking at me, nodding and smiling. But, then I don't realize that she has no one to pick up her insulin from the pharmacy, and she has no transportation to go get it. So, while I think I've adjusted her insulin based on medical literature and evidence-based medicine, what I don't realize is on Friday, she just ran out of her insulin. And, if we don't intervene by Sunday, she'll be admitted to the hospital with a diabetic complication that might put her in the intensive care unit. So, we have a couple of options. We can either send somebody to her home to provide her another vial of insulin, or we can send her to the hospital for four days, risk her life, generate a $10,000 bill, and heaven forbid the human impact of that of spending time in the hospital. That is something that PACE works very hard to avoid, those unnecessary hospitalizations. Take the same example forward that outside PACE, or non-PACE world, that they may not even realize that PACE focuses on - is food insecurity. Yes. Diabetic patients, when we know that they do not have food or possibly at end of the month, they won't have sufficient food. That's where the social worker team starts working on it and connects them to the near organization that can help them with the food security. And, these are the little examples that one of the purpose is like, let's increase PACE awareness. These are the little things that we do. And, even I talked to a lot of medical directors at our National PACE Association conferences. And, the common theme is, give me the sickest patient, I will take care of them, but I have a strong team who will take care of the other things that burns out a primary care doctor outside PACE. Because if you're in the outside world, you can take care of the diabetes, but you have no control over can your patient afford to buy that insulin? Can your patient pick up that insulin? And can your patient even know how to give themselves that insulin? Yeah, you're exactly right. I remember a story - that I don't know if it's an urban legend or not - but, somebody was providing diabetic teaching, and so they were showing a patient how to inject their insulin into an orange. And so in the clinic, they taught them, okay, you inject the orange here. You inject this, that sort of thing. And, then later, they kept increasing the insulin dose because the patient's sugars were just crazy through the roof. They kept going high. They kept increasing the insulin, increasing insulin, and it just didn't touch it at all. Finally, they sent somebody to the patient's home. And this is something that I think PACE does very well. We have a very strong presence providing both home care and home health. And, once you go into somebody's home, you may learn things that you don't see in a standard clinic visit. And so, by this - maybe urban legend - the nurse went to the home, they said, okay, Mrs. Jones, show me how you're doing your insulin. So, the patient reached under the counter, pulled out an orange, injected the insulin into the orange and said, see, I injected here just like you taught me. And then I eat the orange, and then I'm fine, right? It was that moment of epiphany that they realized, no, you're not just supposed to inject the orange. That was part of the teaching. You inject yourself. And so, it wasn't until someone did a home visit that they recognized, oh, you may not fully understand what we're providing to you. So, by being in their home, seeing the use of the medicines that is so valuable. I can't tell you how many times has happened with our patient population. We provide their medicines in these med- packs, where it's very easy for some of our folks that have cognitive impairment. And, let's say about a third of the participants that we have the honor of serving have some degree of cognitive impairment, whether it be memory or things like that. So, we provide their chronic medicines in little bubble packs. So, it's like, here are your pills that you take in the morning, here are the pills that you take in the evening. There's a picture of the medicine. It tells them what each one is. But, I can't tell you how many times we've been adjusting up or down the medicines, and we're all proud of ourselves that we're following evidence based medicine guidelines and titrating this and that. And then you go to their home and you realize they have three months worth of medicine packs and they haven't been taking any of them. So, that is the new relationship connection, that you enhance that relationship and help them understand how important it is to take their medicines and maybe send someone back to their home again in a couple of days to check on them to make sure that they're taking them. I think that's where the brave home health nurses comes in action. And, that's true. Like the orange story that you said, certain stories in health care, we can't make it up. It's there, it's real. And, how we just overcome those challenges to the medications part. One way I notice, of course, the bubble pack was very helpful with patients. If they're traveling, it makes it easy for them. Like, take this medication morning, evening, and nighttime. What I learned during home visit is finding inhalers - a bunch of inhalers that I'll find in patients' homes. And, every time I ask patients that, do you take your inhalers regularly? They will always say, yes. And then, I started changing my question from do you take your inhaler regularly to how many inhalers do you have at home? And they will say, oh, I have four inhalers. Ding, Ding, Ding. That means you are not taking your inhalers regularly because if you are taking regularly, you should not have four inhalers at home. Yes, you're exactly right. And we've found - not to get into the medical weeds - but, for those of you that are familiar with inhalers, some are the short-acting, some are long-acting. And so, the short-acting rescue meds, people may know the term albuterol or Atrovent, or things like that - Ventolin. The patient will say, this one works- because it's short-acting - the other ones don't work. So, I don't take those long acting ones. So, I take this rescue one. I like that. And, I take it 20 times a day. So again, it gives you an opportunity when you find those four extra inhalers in their home to provide that education right in the comfort of their home. And, now, I'll shift a little gear towards the life lessons. Because I feel like life itself is a lesson. And, when I started working with PACE, you realize that how much educating your interdisciplinary team helps. And, I used to do a small 20 minutes session called "Think like a Geriatrician" for the occupational therapist. Think like a geriatrician for transportation, think like a geriatrician for physical therapy. And, it helped. Because the transportation person will come and tell me, oh, Dr. Patel, Miss so-and-so's foot looks a little swollen. And, when I went to pick her up, she was not able to put her shoes on. So, that's like an indicator that helped us like, oh, you know what? Swelling is going up. Do we need to give an extra dose of Lasix, or something? So, I always learned from those little lessons that - teaching, it helps. And, what I want to learn from you today is "think like a soldier", and the lesson learned from you being a military doctor. And, how have you translated that into PACE? And, my very first question, which is what we talked about our interdisciplinary team, which is a strength - backbone of PACE. But, sometimes working with eleven different disciplines, with different personalities, can be very challenging. So, how do you bring your military knowledge to PACE, working with your interdisciplinary team? Yeah, that's a great question. So, there's a couple of ways that I think some of the lessons I learned from a long military career and a couple of tours to Iraq that have been valuable for me in this environment. So, thing number one, I would say, is many times, the patients or the participants that we have the honor of serving, are really kind of alone in the world. That they, again, do not have family that lives locally. They may not even have a lot of social connections. So, I like to think that we are the final backstop. If we don't take care of them, then no one else is going to. It's the same sort of thing when I was in Iraq, I recognized that, hey, as the medical physician taking care of a soldier on the battlefield, if I can't get this done, there's nobody standing in line behind me. And so, it's me, or it's nothing. Now, when in the PACE world, I am part of a team. And so, that is a blessed and wonderful thing. But, we as that collective team recognize if we don't help our participants get this done, there's no one else behind us that's going to do this. So, I think many of our listeners that have multiple involved family members that are checking in on you and helping out with things and maybe an adult daughter, that's driving to help. For many of our participants, that's not the case. And so, I put on that military mindset and say, if we don't help this person now, there's no one standing behind us. And so, let's get this done. Sometimes we even take a very respectful parent role. And so, we do not talk down to our participants. But, sometimes we do almost have a therapeutic intimacy that's almost like a parent - that if somebody, say, has moderate dementia and they will not remember to take their medicines, then we have to put things in place to make sure that they do take their medicines - because no one else is going to do it. We are the final backstop, if you will, for those folks. The second thing I would say, from my military experience, is the benefit of working on a team - and particularly an interdisciplinary team. A lot of times you can end up with division of labor and you can take something that seems like an overwhelming task and break it down into manageable chunks. So, when I was in Iraq, I had to run a lot of trauma codes. Someone would come in with wounds from an IED, or shooting, or things like that. And, it can be very overwhelming to have somebody brought into your tent on a stretcher, not responsive, bleeding, and things like that. That can be very overwhelming. And, if you don't control that panic...bu t, if you can break that down into individual tasks. So, I would say, okay, medic number one, you are left arm IV. Medic number two, you are chest compressions. Medic three, you are going to help strip this soldier's gear off. Nurse one, I want you to draw up this medication for me. Nurse two, I want you to prepare the intubation kit, and then I will plan on getting ready to do the intubation. So, each individual task is not overwhelming. So, that combat medic, for example - which are some of the most heroic people on the planet, are the combat medics - he can say, my world now is left arm IV. That is the only thing I need to worry about in the world right now is left arm IV. So, that sort of division of labor can work in a PACE model as well. No one person needs to do everything. We have our social worker that is looking to assist them with some of the community resources. We have our nurse that is helping them with their medication management. We have the registered dietitian that is providing some of that food support that you mentioned earlier. Each person is doing their individual task, and then, the sum of all those parts create synergy. So, you take what started out as an overwhelming task. It's broken down by division of labor - to each of the IDT members - and, working collectively with a shared mental model, we're able to accomplish that mission. Very good example. Also during especially post-COVID, this topic always comes along - is burnout, and healthcare worker burnout. What lessons did you learn from your military that you can apply here, especially when it comes to preventing either physician burnout, or any healthcare personal burnout? That is a great question. And, I remember one of my mentors I had in the military, who subsequently became a general officer, he gave me a great analogy. He said, you as a - at the time I was a company commander - and, he said, you will be juggling many balls in your life and the higher you go, the more balls that you're juggling. So, if you're the CEO of a hospital, you're juggling more balls than if you're the CEO of a clinic, for example. But, he said an important thing - there are two important lessons to learn. So, lesson number one is some of the balls are rubber, and some of the balls are glass. So, the rubber balls you can temporarily drop and you can pick them up again and get right back to it. That might be something like that project that's due at work in a month. You might be able to take a couple of days off of that and then come back to it over time. That might be a rubber ball. You can pick that one up again. The glass balls are things like your health, your family, your mental health, your spiritual health. Those are things that once you drop them, they may shatter and they may never come back again. So, lesson number one is recognizing which balls are rubber and which balls are glass. Lesson number two, nobody can keep all the balls in the air. I think that is one thing that we as physicians in particular think that we're invincible. We're bulletproof. We can keep all the balls in the air, but no human can. And so, important to recognize that which of these balls can I set down, just for a moment, and then keep juggling - and which of the balls are glass that if I drop them, they'll shatter. Wow. Very well said. I'm loving this. And now, nationwide, we always talk about our health system - or healthcare is so expensive in the United States, and we are not the best when it comes to delivering quality of care. I feel like in PACE, we have learned that to decrease the utilization and improving the quality of care. But, I also think in PACE, we still have opportunities. Now, when you are in Iraq, you don't have all the resources, but you still try to do your best that you can. Especially resources, like, you don't have a CT scan that with one fall, you can scan the head and abdomen and back and everything. From that lesson, being in the military with limited resources, how do you apply in PACE that you can do the best job without compromising the care by decreasing utilization? Yeah, great question, Dr. Patel. Utilization, in any medical setting, is always a challenge. And so, I think that some of the things I learned, providing care in a very austere environment is that you oftentimes can provide excellent care with a relatively few number of resources. Now, in the world of PACE, we are very blessed because we have a lot of resources that we can apply to the participant, but you have to be wise about it and you have to have a shared discussion with the patient on what they want. So, for example, many of our patients are in the 8th or 9th decade of life. They may not want a mega-workup. It's thought that as you look across the nation and PACE programs, the average PACE participant takes part in a PACE program maybe only for two or three years. Now, that's changing over time as our PACE population gets younger while the rest of the world is getting older. There's a lot of reasons for that. But imagine, if you will, you're sitting down with a 95 year old woman, and she needs help with a lot of her activities of daily living. She needs help dressing. She needs help bathing. She may even have some moderate dementia. And, you are able to tell her, Mrs. Jones, on your chest x-ray, there was a little pulmonary nodule. Now, we have a shared discussion. Then what would you like us to do for this nodule? Do you want us to do a workup for it? Do you want us to do CT scans? Understand that sometimes the treatment is worse than the disease itself. And so, some of our elderly participants may sort of be harmed by an extensive workup. You may have something that would only become a problem 20 years from now. And, the woman in front of you is 95 years old. She might have a life expectancy of 18 months. Do we really want to do an open biopsy of something in the chest? Boy, perhaps not. And, I've had many participants kind of look me in the eye and say, Dr. Colt, I don't want to do that. Just keep me comfortable. I want to go home. I want to spend time with my cats. I want to watch my favorite TV show. I want to be able to see a granddaughter if there's someone in the picture, but I just want to be comfortable. And so, by embracing that paradigm, that might almost be like a primary palliative care, if you will, a comfort-based care when appropriate. There's a famous saying that I know you're familiar with as a geriatrician, that some of the best geriatricians just go through and take off medicines that have been on the patient. Someone submitted the hospital, they add four new medicines, and then they become like barnacles. They're just on there for the rest of their life because no one has the courage to stop it. So, sometimes sitting down with a patient and saying, ma'am, you've been on this acid-blocking medicine, this PPI, for the past couple of years. Do you ever have heartburn? No, I've never had heartburn. They started that when I was in the hospital. So, you've never had heartburn? No. Well, why don't we try you off it for a week, and then they come back a week later. Did you have any heartburn? No, didn't have any heartburn. Well, maybe we'll just stop that acid reflux medicine because you don't need it, and it just simplifies their medication regime and it's one less pill for them to take. So, those are just a couple of examples. That's what I call geriatricians' high, which is deprescribing the medication. And, I always tell all the PACE medical directors that - you know, work with your pharmacist and get on the polypharmacy calls because those are the ones that help. Like, when I was a PACE medical director, CareKinesis was my pharmacy, and, me and my providers were on call with them regularly. And, we deprescribe so many medications that equals to decrease adverse drug event, that equals to decrease unnecessary utilization. Yes. No, you're exactly right, Dr. Patel. And, I think depending on the studies you read, once you're on five medicines, six medicines, there's almost a 100% chance that you're going to have some drug-drug interaction. And, medication A is going to interfere with medication B. So, then you have to start medication C to counteract the side effect, but then that interacts with medication D. So, then you need to start another medicine to take care of that side effect. And you can just see it becomes you got a whole bowl full of jelly beans practically when you take your medicines every day. I agree. Deprescribing is a great opportunity and pays off - to all the listeners - deprescribing is one of the great opportunities when the new participant comes to your program, work with your pharmacist, and start deprescribing medications. I feel like that's the best place to start - deprescribing medication. Also, now, Dr. Colt, I realized in PACE, like, nobody teaches us business in medical school. We learn business in PACE. Now, as a doctor talking about numbers and bottom lines and revenue and costs, what do you have to say to other doctors, even outside PACE or in PACE? The future is doctors have to learn the business side and tell me about your experience doing MBA and how that helped you in the medical director role at PACE. Yeah, exactly right. I think one of the things that going to business school and then applying that to health care helped me to recognize is that the PACE model is the right way to go. So, the PACE model is sort of a capitated system. Now that's a good 25 cent word to say that you are paid sort of a fixed amount to provide all the medical needs. And so, the benefit of that is, it is different than a fee-for-service model. So, in a fee-for-service model, you are compensated more for seeing the patient more. So, if I were in - this is not to malign or drop dimes on my brothers and sisters and fee for service - but, if you see a patient on Monday, and then you bring them back on Tuesday, and then you bring them back on Wednesday, in a fee- for-service model, you're getting paid for that individual visit each time. So, you can see that it behooves you to do more volume, a higher volume of service. And, it doesn't really matter that much as far as if they get into the hospital or things like that because you're paid just by volume of seeing them. The benefit of a capitated model where you're really sort of - it becomes a team effort that you and the patient are working together to avoid unnecessary medical care. So, if I have no incentive to see you 20 times in a month, then I may not think it's needed or necessary to see you 20 times in a month. Maybe if I see you twice in a month, we can provide good medical care, and that's a reasonable way forward. It eliminates this sort of churn where you're doing more and achieving less. It focuses on what can we do to decrease bad outcomes? What can we do to minimize unnecessary hospitalizations? What can we do to minimize an emergency room visit? It just helps align those incentives, both of the participants and of society at large. It just came to my mind when I'm listening to your conversation about veterans, and you know how VA health system is on its own, and not a lot of veterans have access to care, that a VA center will be 5 miles or ten mile radius from them. A lot of veterans lives in different parts. Is there an opportunity that veterans can possibly benefit from a PACE center if it's nearby something to think about or bring it to the policymakers? Yes, that is a great question, Dr. Patel. And, I will say that we do have the honor of serving several veterans in our program. The interesting thing with our program is that we almost exclusively serve an underserved population, and there are many veterans out there that are underserved. Absolutely. And so, in that case, many veterans could probably benefit from a PACE program. Now, generally, as I mentioned earlier in the interview, 90% of our participants are both Medicare-eligible and Medicaid- eligible, which in California is Medi-Cal. So, that has certain income restrictions. So, the majority of the people that we serve have very low income. I'm talking about people living on $400 a month, $800 a month. And so, let's say if you're a veteran and you had 20 years of service and you had a retirement or sort of a medical monthly payment, you might, interestingly enough, make enough money that you might not be eligible for Medicaid. And so, then it might be a little bit more challenging to take part in a PACE program, but it's still possible. I would recommend each individual case needs a little bit of attention to detail, needs a little bit of work. We have some superstars on our enrollment team that, here in San Diego, would be more than happy if somebody lives in North County, San Diego, and you have questions about PACE, our enrollment folks would be delighted to sit down and review those cases with you. Great. Let's talk a little bit about now the post-COVID world, or people call new normal, but I always challenge them. Why don't we call new better? Why settle with normal? So, with this new better world, what are the one or two things that - lesson learned from COVID - that you were not doing before and you are doing now. Very true. So, if you go back in time a bit. So, our center had been open for about six months when the COVID pandemic first fired up. And, as you might imagine, it was devastating for our population. Our seniors that have multiple medical conditions, chronic obstructive pulmonary disease, congestive heart failure, diabetes. They were particularly vulnerable to the COVID pandemic. And, I'm sad to say that even with the best of efforts of modern medicine, we lost several people to the COVID pandemic. And, that was a tragedy. Each individual life lost like that is a tragedy. What the pandemic taught us is that a lot of care can be provided in participants' homes. So, we adjusted very quickly, rapidly, and nimbly when the pandemic first started. We have a state of the art day center here that we're, prior to the pandemic, we were bringing people in for socialization visits. What we ended up doing is temporarily suspending our day center operations for social visits. We kept our clinic operational through the entire pandemic. We kept our rehabilitation center operational through the entire pandemic. But increasingly, we supported our participants in their home. We started doing home visits. We would send nurses out to the home. We use technology, things like care.coach tablets, which provided sort of a balm to that social isolation, if you will. We put technology into many of our participants' homes, where, at any given time of the day, they could push one button and they could talk to a human being if they needed social support. They had loneliness. They had depression, anxiety, panic. They could use technology that we provided for them to speak to a human being on the other side that cared for them. Again, more and more we're doing that care either virtually, telehealth, home visits, and then bringing people to the center only when they absolutely needed that. So, now that the pandemic is - praise the Lord - finally receding, if you will - starting to go away, we now are starting to question maybe some of these lessons learned is we can provide excellent care in the home. It's easier to send a nurse, say, to a participant's home and provide a brief service a wound care, for example, rather than sending a van out to their home, pick up a frail, vulnerable, uncomfortable individual, bring them to the day center, provide that wound care there, and then take them back to their home. There may be a better way to do it, and it may be by providing more care in the home. That is the new, better world. And, thank you for sharing that with us. We love every episode. We love to hear a success participant story. Do you have a story to share with us? Boy, there are so many I can think of to choose from. One of the blessings that we get collectively is we will have participants that are going to the emergency room as their only source of care. And so, we've had participants that have gone to the emergency room four times a month, five times a month, eight times a month before coming to PACE. And, then, they come in and see us and we can take care of them. I think of one gentleman in particular, who, when he came to us, he had a lot of medical problems, a lot of medical interventions that he needed. And, because he was not able to transport himself, he would just have to call 911. So, after bringing him into the program, we started providing a lot of care for him in his home. And, we knew that historically he would often go to the emergency room by 911 on Saturday or Sunday. So, what we got in the habit of doing is we would send our visiting nurse out to his home every Friday afternoon and we would say, hello, Mr. Jones, it's good to see you. Do you need anything? Here are some extra medications for you. Here are some extra dressing supplies, here's some food to make sure that you have it - just to make sure that he had his sort of Friday afternoon tune-up. And, by doing that, we greatly decreased his ER visits. He then almost never had to go to the emergency room on a Saturday or Sunday because he knew that we would see him Friday and then oftentimes we would see him Monday. For many of these isolated senior citizens, it becomes a question of fear. It's fear of the unknown. I have these symptoms going on. I'm not a doctor. I don't know what it is. I'm worried it could be very serious. And so, the only offer they have is to call 911 and go to the emergency room. Now, as part of PACE program, they can call us on the phone, we can do a video visit. Maybe we can send a nurse to the home, maybe we can bring them into the clinic if that's appropriate. And, that helps take away that fear. They know that PACE is here for me and somebody's going to answer the phone 24/7, even in the middle of the night or weekends, we have an on call nurse service where they will have a friendly human being that answers the phone in the middle of the night if they need to talk to somebody. So, by providing that wraparound support 24/7,365, that helps take away the fear and it helps care for our participants in the comfort of their home. I love the word that you use - Friday tune-up. Yes. It's amazing. It's like a care package you're delivering to your participants. Make sure you have everything that you need until Monday. Absolutely. We are coming more towards the end of our episode, but, before I go to the rapid- fire rounds, I have two questions. If you could step into my shoes, what would you ask yourself that I didn't ask you? Let's see. Maybe I would say, Dr. Colt, are you guys doing any new ventures to provide better care for your participants? And? And then, I would say, if I were hypothetically asked such a question, we have a new venture that we've been trying something called DocGo. Okay. And, that is a mobile nurse resource that we are using to provide both acute care, as well as scheduled chronic care. And so, we have a nurse that is in a vehicle that is kind of going around in our service area, and they're providing care to participants in their home. But, the good news is that if we have someone that develops acute symptoms and they say, let's say, I'm having swelling in my legs. I've got this redness that's on this cut that I got yesterday. I'm not sure if I should go to the emergency room. We can there in a relatively short period of time, send our DocGo nurse out to the home. They will be able to see the participant eyeball to eyeball, check out their symptoms. If they can deal with it at the RN level, then they take care of it there. If they need to call back to the provider here at the clinic, they can even do a video visit. So, either myself or one of our other providers can look at the swollen legs, can look at that redness, and we can prescribe medications right there at the point of care, and, that may avoid an unnecessary ER visit. So, the DocGo pilot we've been doing for a number of weeks now. It's already been very successful. And, I think our participants love it. They know that they may not have to go to the emergency room and sit and wait for hours and expose themselves to potential infections and things like that. We can send the treatment right to the comfort of their home. And so, that's one of the exciting pilot projects that we've been working on today. Wow. I'm glad I'm asking this question. So, is it like a special van or a regular van that the nurse drives around but is more equipped to do, like putting an IV, and everything? Yeah, you're exactly right. It's a more equipped van. It's sort of like we figure out all the things that a nurse might be able to do in the home. We provide them with wound care materials. We provide them with catheters, we provide them with bandages and dressings and even things like immunization sometimes. So, we've used sometimes our visiting nurses to give coverage shots, to give flu shots, things like that. So, we just think ahead. If they need to draw blood, for example, we'll give them all the appropriate tubes, the needles, the alcohol wipes, all the things. So, it's almost like we bring the clinic into the participant's home to provide an excellent quality of care right there in the home. And so, I think the DocGo partnership has already been very valuable. We have some people that likely have averted an ER visit just over the past couple of weeks. And, that's good for everybody. That's good for the participant. It's good for the participant's family, and it's good for society. That is amazing. So, is this a third party that you use or it's one of your own? So, this is a third party. DocGo is an independent company that we have partnered with. They have sites sort of in different parts of the country. We are sort of their first big California mission for Southern California, but it's been a very valuable partnership thus far. I cannot wait to hear more results about it. Keep me updated with the results with that. Absolutely. And, then, how can listeners connect to you? What I would recommend is many of the people listening to our chat may have somebody that they think might benefit from PACE. They might say my father, my grandmother, my uncle, my friend might benefit from PACE. You think maybe I could plug them in with somebody? And, what I would say is there's a couple of ways to get a hold of us. You could always Google Gary and Mary West PACE, or even if you just did West PACE, that would likely bring you to our website. There's a lot of information on the website as well as some contact information. I can give you our primary telephone number, which is answered 24/7. For those of you that have pens ready, that would be 760-280-2230. I say again, 760-280-2230. Or just Google Gary and Mary West PACE. And that will bring you up to our website. Because I think that like I was sharing before, there is a lot of unmet need out there. And, people may just not be aware that there are compassionate, competent professionals that are standing by to help you or help your loved ones. Thank you. Now we will go into my favorite part of the show, which is the rapid-fire round. I will ask you five questions, and you can answer them in one to two sentences. All right. What does failing mean to you? So, failing to me means not doing everything in my power to support my participants - that we've turned over every stone, every discipline has leaned in to provide a platinum level of care. Good. Describe PACE in one sentence. PACE is an all-inclusive program of professionals working together to keep vulnerable seniors living at home for as long as safely possible. Great. If you had a magic wand, what is the one thing you would change about PACE? I would use my magic wand to expand the reach of PACE so that we could serve more people. Thank you. Who inspired you and why? I have been inspired by many mentors in military medicine to serve. That is over and over the recurring theme. It is an honor to serve. I've followed in the footsteps of giants, and it is an honor to serve. Serve. Seva. Thank you - thank you for that. One positive message for our listeners? We in PACE are making things better. We are providing a platinum level of service to fragile, irreplaceable precious seniors to keep them living at home for as long as safely possible. Well, we are at time. Thank you, Dr. Colt, for being our guest. Thank you for your service to our country, and it was a pleasure speaking with you. Thank you, Dr. Patel. It was truly an honor and a privilege to speak with you today. 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.