Palliative Care in Rural America: An Interview with Michael Fratkin

Eric: Welcome to the GeriPal Podcast, this is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who is our guest today?

Alex: Today we have Michael Fratkin, who is a palliative care clinician, and founder, CEO, CMO, chief bottle washer, soup to nuts, everything of ResolutionCare, which is a palliative care service for rural and resource-poor settings in Northern California, based in Arcadia, California. Michael, welcome to the GeriPal Podcast.

Michael: Thanks gentlemen, pleasure to be here.

Eric: And we start off with our guest requesting a song from Alex Smith. Michael, do you got a song for Alex?

Michael: Yeah, it’s “From Great Heights” by Iron and Wine.

Alex: This is a terrific song. I think the second Iron and Wine song that we’re playing here for the GeriPal podcast. I will try to do it some justice.

Alex sings “From Great Heights” by Iron and Wine.

Eric: Lovely!

Michael: Uh-hum (affirmative). Thank you so much Alex, I just want you to go on and on, and play that circular song over again! Thank you so much.

Alex: We can only do a snippet.

Michael: So be it.

Eric: So Michael, tell us a little about ResolutionCare.

Michael: Oh my goodness! ResolutionCare is a product of a burned-out, under-resourced, rural palliative care physician, who just wanted to believe that there was a better way, a different way. I live up here in beautiful far Northern California, in a community I’m in love with, I’ve been here for 20 years.

Eric: And that’s several hundred miles away from San Francisco, is that right?

Michael: Yeah, it’s 250 plus miles from San Francisco. And it’s gorgeous; empty beaches, and redwood forests, and six wild and scenic rivers. Yeah, it’s just lovely up here, I’ve been here for 20 years. In 2014, I had kind of come to the end of my rope. There was four or five consults for every one that I could actually do. I had very little in the way of resources on the ground. I was trying to do some community-based worked, and I just didn’t have any resources to do that.

Eric: So what did you do?

Michael: Well, first thing I did was look around the world and look for another job. I looked for jobs down in the Bay area, Santa Rosa. They’re not hard to find for an experienced palliative care docs, but then I kept driving home. And I’ve fallen in love with my trees again, and not wanting to leave. So the short version is, I cooked up a scheme to launch a crowd-funding campaign, in the fall of 2014, and it worked. I crowd-funded it, an advanced illness management and end of life care team from our rural community that raised $140,000.

Eric: Wow.

Michael: Yeah, crazy. And a few weeks later I walked into a donated office space in January and that’s when we started. Now, two years later, we’re taking care of 132 people in their homes, in our extended local environment. Our range is about 200 miles, in three out of four directions. We don’t see anybody out in the ocean. In the other direction we see lots of folks.

Eric: Do you go up to the border with Oregon?

Michael: Yeah, we go all the way to the edge of the border with Oregon. Crescent City in Del Norte is the outpost on that corner of things. That’s about 80, 90 miles north. And then to the east we’ve taken care of people as much as 150 miles east, almost to Redding. And then south, to Piercy past Garberville. There’s a whole lot of California without any palliative care services. And we’re extending our reach in every direction we can think of, with every trick in the book.

Eric: I’d love to talk about some of the challenges in delivering palliative care in rural areas. One of the things that you’re bringing up is the distances that it may take to actually reach someone. How do you guys deal with that?

Michael: Well, we deal with it in one of two ways. We don’t actually have a clinic or an office space where people come to us. We go to them, and we see them in one of two ways. One way is, we drive out to their house, and go through their front door, and sit on their couch, and deal with their dogs, and eat their cookies, and do home visits, in the traditional, powerful and amazing house call tradition.

But the other is the use of video conferencing. In that scenario, what we do is we get people set up with the technology, send them an email, they click on a hyperlink, and we do the same. And boom, there they are, face-to-face, looking through a window or a frame, at their practitioner. Whether it’s their doctor, their nurse, there social worker, their chaplain, or even our community health workers.

So either we go to their home in person, or we do it in that virtual fashion, which is really an interesting new modality for doing this work.

Alex: Say more about how this works in terms of the technical nuts and bolts. Do you send them a software program to use, or do you actually send them, say, an iPad or a laptop?

Michael: Probably about two thirds of our patients have all the gear and gizmos they need to participate. And all they have to do is go to a site and download a simple app on to any device with a front-facing camera. So it’s as simple as that. For them, they’ve got connectivity, they’ve got a gizmo, they generally know how to use it. For another group of our patients, we have to do a little bit more hand-holding. And for some people who don’t have connectivity, either because they live off the grid, out 150 miles in the country side. In some circumstances, we’ll just go ahead and throw a satellite dish on their roof, and lend them an iPad during the time that we’re caring for them.

When you think about that kind of investment, it may not seem very medical, but at the end of the day, that three, four hundred dollars of investment can deliver unbelievable value to people who are too bloody sick to waste their time driving two hours to sit in some crappy waiting room and deal with old people magazines and clipboards shoved in their face and all the rest of that. All they really have to do once we get then set up is click on a link, while they’re sitting on their couch. And all I have to do is click on a link, and I’m connected. The efficiencies are incredible.

Alex: So Michael, there must be some trade-offs between being able to be in person for palliative care consults, I think about the consults I do in person in the hospital. That sense of presence and being there, touch, is so important to the work that we do. And yet I’m sure there are ways in which you’re surprised at what you’re able to accomplish with video consults or tele-consults. Can you talk about that, and talk about what you do lose?

Michael: Oh, for real. It’s pretty amazing what you don’t lose. But what you do lose is access to some of the best home-baked cookies in the world. You lose the ability sometimes to just throw your arms around somebody that you’ve been working with over time. There’s a particular physicality or tenderness that comes with just being together with people who are going through such hard stuff, and who are looking for guidance from a trusted relationship. And so some of that they give up. Some of the satisfaction that’s reciprocal, I give up.

I gotta tell you guys something, it’s pretty amazing! I had no idea that our work could be done in this fashion, until I tried it. So back in 2014, before I launched the crowd-funding campaign, I test drove the idea, and put it out there to the world through a little application that Google had for a minute, called Google Helpouts. It was this way of interacting with the world, and saying, “Hey, I’ve got something, and if you want it, you can connect with me directly and I’ll share that expertise.” So I put something up for end of life counseling, and over the course of a month, I got five or six contacts from people in all kinds of medical situations. And it was amazing, that in about 30 seconds, the technology itself just disappears. And there you are, in a very intimate relational space, a very unique relational space, that has it’s own advantages, as well as the obvious trade-offs that we were talking about.

So, no, I can’t drink their tea and coffee, and eat their cookies and deal with their dog, but what I do get is this crazy phenomenon where people don’t show up so much as patients, so when a person need only click on a link and then be face to face in the comfort of their own home, in their own locus of control, with their doctor, neither one of us actually show up in our medically defined identities. They are just a person, sitting on a couch, and interacting with another person who might have something of value to them. And so there are enormous advantages to this new kind of medium, this new window, to connect with people.

For example, when a doctor goes to a person’s house, that’s a big deal. You walk through the door and you’ve invaded their space. There’s a lot of people who have a lot of anxiety about what their house looks like, or how they keep things, or fear about their dog, or are you allergic, or what the heck. And that’s not there. They get to show you what they want to show you. And if I want to see their garden, or what they keep in the refrigerator, or how they manage their medications, I ask them to do that. And if they want to show me, they show me. And if they don’t, they don’t. But they’re sitting there in their fuzzy slippers, comfortable with their cats and dogs on their laps. And what is really remarkable, is that the encounter that I typically would take 90 to 120 minutes for, say an initial patient consultation, it actually tends to be done in about 50 or 60% of the time. Wrap your head around that.

Eric: Is there an issue … Actually, I’m going to take a big step back. How does this all get paid for?

Michael: That’s a very good question. There are some progressive innovative health plans, willing to partner with providers of palliative care, under the concept of value-based payment. In other words, they’re interested in aligning what they do, the financing of health care, with what we do, the provision of health care, around some very simple outcomes that everybody’s heard of. The health plan, and the provider, want the very same things. They want people to have improved quality of life. They want people to be more satisfied with their experience. And they also want people to use only the value of the system that serves them, and not excessive high-cost, low-value interventions. In other words, the health plan is very invested in saving money. Which is not all that hard to do in the care of people in the last part of their life. In the typical motto, so much uncoordinated, fragmented care occurs in emergency rooms in hospitals because people don’t have an alternative.

They engage with us to provide palliative care to their members with the idea that they don’t really care how much we see them, how many times we see them, in what fashion we see them, whether we see them with video conferencing, or face to face, or whether we see them through messages carried by pigeons across the community. They don’t really care, they care about the outcome, and so do we. And so then we can construct, when we’re paid for on a value-based, or a capitative per member per month basis. We can then construct a very personalized, very customized treatment plan, based on what makes sense for that individual person.

Alex: Michael, tell us how this integrates with hospice, and how it’s distinct from provision of hospice in these rural, resource-poor settings.

Michael: Just like in other places, where hospice is available within a 50-mile radius of their headquarters, which is nearby where our headquarters is, whenever we have a patient who becomes eligible for hospice services, they’ve already heard from the palliative care service about the value of that specialized form of palliative care. Outside of that 50-mile radius, we do the best that we can, at a distance, for people, who wish to stay on their own homes and property, but don’t have available hospice services. At least not through a Medicare-certified hospice.

Eric: What does your … Do you have a professional team? Is it just you? What does your service look like?

Michael: Back in the day, back before I had this, when I was burning out, I didn’t. I had a part-time social worker at the hospital, and we couldn’t barely even come close to keeping up. That was the problem, I was looking to the hospital system I’d been a part of to resource the program and provide an interdisciplinary team, so the patients got what they needed and I wasn’t going completely bananas all the time.

That couldn’t happen from the inside, so the crowd-funding campaign, some pilot programs on value-based payment, and some other more mature contracts have evolved. So now we’ve got 17 people in our operation, which include another partner, a palliative care physician, four nurses, one of which is the clinical manager, two social workers, a chaplain, and three community health workers. All of us working in an integrated and coordinated fashion, to do what makes sense for about 132 people, at least today.

Alex: What are the main services you provide? If you had to summarize, we see mostly this kind of patient, and these are the main issues that come up that we address.

Michael: I’m just going to say, for all of our listeners, and for you guys, the main ingredient of palliative care is love and respect. That’s what we provide, and we do that wearing our nurse hat, doctor hat, social worker hat, community health worker hat, etc. That looks like palliative care anywhere. Where we try to be very nimble and expert at the management of symptoms. Where we work on all the pesky social determinants like food, housing, that sort of thing with our social workers. We are, I hope, really good at communication and advanced care planning. We help our colleagues in oncology and other specialties with difficult transitions of care. We facilitate appropriate transitions to hospice as soon as that’s the right next step for people.

We also do some pretty unique things. We have a set of projects that people go to the website and look under the tab videos. It’s ResolutionCare.com, by the way, www.ResolutionCare.com. If you look at the video section, you’ll see that we’ve made a series of steadily improving videos that kind of get us out of the way, and give folks that we’ve cared for the opportunity to talk about who and what they are, and how they see what this phase of life is about. So we’re doing some messaging.

In our non-profit organization, ResolutionCare Institute, we’re doing primary palliative care education, using a very powerful model from the University of New Mexico, called Project Echo. And that’s a way that we’ve taken our interdisciplinary team, and then engaged with community health programs, or community health clinics in Northern California, to teach them the basics of symptom control, communication, and advanced care planning, in this very dynamic learning community that sets us up as a hub, and them up as spokes, to go through a curriculum in palliative care, so that the primary care providers know the mindset of palliative care and how to approach some of the more common problems.

Eric: Like you mentioned before, access to palliative care in rural America is shockingly low, or, if not, absent. Are there things that palliative care providers, and really other providers … Are there reasons why they should consider working in rural areas and delivering this type of care in rural areas?

Michael: Yeah. I’m sitting on the back side of the hospital, in a redwood forest, with blooming rhododendrons, on a sunny day, maybe a little bit rare sunny day here in Humboldt County. To be able to drive five minutes from work and be at my house, which is five acres in a redwood forest with a beautiful view, to raise my kids in this kind of environment, is non-negotiable for me. And then utilizing these technologies to connect to people at a distance, have allowed me to have a lot more freedom, and a lot more balance in my life.

Eric: Are there other things, like if I went up there and shadowed you for a week, do you think that would surprise me about delivering palliative care in rural areas?

Michael: We’ve got a pretty rough population of folks that are disadvantaged or really challenged by all the social determinants and stuff. We’ve got plenty of drug use up here, plenty of people that are homeless. There are certain qualities of that group of folks in our practice that are a little bit different than that group of folks in your practice. There’s a lot more marijuana up here in Humboldt County, I guess you could say.

Eric: I’ve heard about that.

Michael: Have you heard about that? People have to look for the sense of place that makes sense for them, and for their families, and for their sense of how they want to live their lives. But I think I would let you come up here and find out for yourself. The other thing that we can do any time you like, is you can drop in from right where you sit, to participate and engage with our folks. One of the tricks that this technology allows, is that I can do a family visit with people from all over the country, in a way that’s much easier than all of the wringing of the hands, and stressing out of emergency plane flights, all the rest of it.

So if I can, I’ll tell you a little story about how I see telemedicine. Telemedicine 1.0 was a great set of ideas about 15, 20 years ago that came from big academic medical centers, like UC Davis and Washington University in St. Louis. Where they built buildings, put big bandwidth pipes, T1 cables and fiber optic pipes, and they laid them on the ground to connect to spoke sites in rural areas. They built these telehealth centers, and you would schedule people to go to the center to engage with the specialists that were based in Davis. And it totally proved that you can do good cognitive medicine using telemedicine. The problem was the barrier for entry was high, it cost so much money to build out all that stuff.

Well then these things called smartphones popped up about 10 years ago, and cloud-based computing, and bandwidth requirements became ubiquitous, it was just possible to do all kinds of things. Like, for example, I think the three of us on this podcast are in three different places, doing a high-quality audio encounter in real time.

Alex: Well, Eric and I are together.

Michael: Oh you guys are together. Okay, good. Well, you get the point.

Alex: Right, right. Theocratically we could be in different places.

Michael: So that’s tele-medicine 2.0, and the people that have really been advancing that are organizations like Doctors on Demand, and Teladoc, and American Well; people who are really pushing this idea that you can do brief, episodic urgent care-like connections for sniffy noses and sore throats, and save people the difficulty of having to leave work, and take a half a day, and the cost of all that stuff.

What we’re doing is what I call tele-medicine 3.0. And that’s just taking this technology a step further to engage in longitudinal and more intimate relationships with people that have serious illness.

But telemedicine 4.0… I’ll just tell you a story. I was called to the hospital awhile back for a 70 year old, who needed that typical late-in-the-course transitional conversation. This is a guy with diabetes and hypertension, and a history of a few strokes. He was also a Native American fellow with a long history of being very committed to his community. Anyways, he came in with pneumonia and sepsis, and he just wasn’t making it, so I was asked to come in and talk with him. So I walk into the room, and in the room is his 93 year old mother, and three or four other generations, from babes in arms, to aunts and uncles and cousins. But at the end of the bed there was a cart, and on that cart was a laptop computer, and on that laptop computer was a video conferencing platform with five other members of the family, from places like Maryland, Los Angeles, Sacramento, one other place. In other words, the room was over-filled with a synchronous communication of all those family members.

And we did the thing, that you’ve done so times, and brought value to families to help them make that transition with a sense of resolve and on the same page. But the cool thing about it, and the reason that I say it’s telemedicine 4.0, is that I didn’t have anything to do with setting it up.

Eric: Do you think regulations are keeping up with the technology right now? ‘Cause when I hear a family member having some type of video conferencing uplink up, I also think, oh my God, what are the HIPPA regulations on that?

Michael: The regulations are definitely not keeping up with the technology. So you just have to decide which kind of person are you. Are you a person that’s going to ask for permission before doing useful things that are right there at your fingertips?

Eric: Or just forgiveness later.

Michael: Or forgiveness. That’s me. You might have guessed that about me. I’m kind of a forgiveness guy.

Eric: Last question from me is, what do you think the field of palliative care nationally should be doing to improve access to palliative care in rural America?

Michael: I think that’s a great question. The legislative and policy work that would have CMS catch up with the development of these kinds of applications of telehealth would be very, very valuable. I think value-based payments and outcome-based payments that bring together the partnership of payers and providers to solve real problems for rural America, that would be very useful. And I think that looking towards the intermediate future, building more opportunities for palliative care training. The PCHETA legislation looks like it has some life in a strange legislative environment in Washington DC right now.

But really I think the other part of it is related to knowing that we’ll never have enough specialty palliative care providers, and that the real value of having an expertise, is not holding it as a value proposition, but sharing it. And palliative care has this unique opportunity as one of the only intrinsically whole person perspectives on the practice of medicine and the health care system. We need to share that up and share that out with all the other specialties in medicine, and engage them in finding their own satisfaction that comes when you actually look at the people you’re dealing with as people, not as either sources of revenue or problems to solve.

Eric: Great. Michael, I want to thank you for joining us today. We’re gonna have links to Resolution Care, to other things that we talked about, including the PCHETA bill, currently, hopefully going through the congressional steps to get it approved. And again, very big thank you for joining us today.

Michael: Thrilled. That was very fun to do this gentlemen. Thank for having me.

Eric: Great, Alex, do you want to close us off with another verse?

Alex: Sure.

Alex sings “From Great Heights” by Iron and Wine.

produced by: Sean Lang-Brown