Rural Palliative Care: Karl Bezak, Jeanie Youngwerth, Adie Goldberg, and Gregg Vandekieft

Eric 00:16

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:19

This is Alex Smith.

Eric 00:20

And Alex, we have a full house for a podcast on rural palliative care.

Alex 00:23

We have a full house for rural palliative care. Jeanie Youngwerth is our first guest guest. She is a palliative care doctor at the University of Colorado. Jeanie, welcome to the GeriPal Podcast.

Jeanie 00:34

Excited to be here. Thank you.

Alex 00:36

We’re delighted to welcome Adie Goldberg, who’s a palliative care social worker and clinical coordinator of the Washington State Rural Palliative Care Initiative. Adie welcome to the GeriPal Podcast.

Adie 00:49

Glad to be here.

Alex 00:51

And delighted to welcome Karl Bezak, who’s a palliative care doctor at the University of Pittsburgh and UPMC. Karl, welcome to GeriPal.

Karl 01:00

Thanks for the invite. Glad to be here.

Alex 01:02

And last, but certainly not least, dear friend from many meetings go back a long way. Gregg Vandekieft, who’s a palliative care doc, works at Providence St. Peter Hospital in Olympia, Washington, is medical director of the Washington State Rural Palliative Care Initiative. Gregg, welcome to the GeriPal Podcast.

Gregg 01:22

It’s great to be here, and I’m going to share. Alex and Eric, I heard Sterling Harjo being interviewed by Terry Gross, and he said, you know, Terry, I always knew that I would have made it if I got to be interviewed by you. That’s kind of how it feels being interviewed by the two of you. It feels like we made it.

Eric 01:38

Yeah. Yeah. No, yeah. You don’t need Terry Gross anymore. You’re right.

Eric 01:46

Okay. We got a lot of talk about rural palliative care, but before we do, we always start off with song request. Gregg, do you have the song request for Alex?

Gregg 01:53

Yeah. Three Dog Night’s Out in the Country.

Eric 01:56

Why did you choose this song?

Gregg 01:59

Well, when I was thinking about the bleak health economics landscape in rural communities, I first thought of John Mellencamp’s Rain on the Scarecrow, but that’s too depressing. I wanted something more uplifting. And Three Dog Night was a big band in my childhood, so I thought out in the country by Three Dog Night.

Eric 02:14

Wonderful.

Alex 02:22

(singing)

Eric 03:06

Wonderful song. Good choice, Gregg.

Karl 03:10

That’s a lot.

Eric 03:11

All right. We’ve got a lot to cover. I wanted to start off personally, just briefly from each of you, kind of what motivated you to do work in rural communities, especially rural palliative care? Adie, I’m gonna start off with you. What got you to do this type of work?

Adie 03:28

Well, I had the opportunity to work in a tertiary hospital in southwestern Oregon, and I watched patients come in from Northern California and eastern Oregon, and I watched these beautiful discharge plans get derailed within 48 hours of patients going home.

Alex 03:48

Yeah.

Adie 03:49

And so I did my PhD dissertation on a seamless delivery of palliative care in rural Washington, Oregon. Forget which state I’m in. Anyhow, it just, you know, my heart’s there. I went to college real close to where Gregg grew up in a small town in Iowa. And I. My heart’s in rural communities.

Alex 04:08

Yeah.

Eric 04:09

Do you live in a rural community?

Adie 04:11

I live in Spokane, Washington, which people in Seattle would say is rural.

Alex 04:16

It’s all relative, right?

Adie 04:18

Yeah, but no, but I have a cabin, so.

Alex 04:21

Oh, you have a cabin?

Karl 04:22

Yeah.

Eric 04:23

How about you, Jeanne?

Jeanie 04:25

I would say mine was by opportunity. It came across one day that some folks from rural Colorado reached out and wanted to collaborate. I’d love to do innovation. I think I’m like most Coloradans where we love the mountains, we respect the mountains, and anything that we can do to help our colleagues in that area and patients to access palliative care. So this just sounded. It sound exciting and fun and meaningful.

Eric 04:52

That’s wonderful, Karl.

Karl 04:54

Yeah, well, I. He found me, to be honest. I was a fellow at Mount Sinai back in 2018, 19, and I met Bob Arnold, who I suspect many of you know, and he had a fantastic project using AI to identify patients in rural areas in western Pennsylvania. And it drew me after a fellowship, and I’ve never looked back. It’s been a fantastic thing working in rural communities with telepalliative care, and it really aligns with who I am, my passion for equity and access to our specialty.

Alex 05:25

Yeah.

Eric 05:25

2018. AI. That’s like pre chat early.

Karl 05:30

Oh, yeah, yeah, yeah. Early adopters, for sure.

Eric 05:34

All right, Gregg, how’d you get interested in this?

Gregg 05:37

As Ad mentioned, I grew up in farm country in a small town in Iowa, and then my first practice out of residency was in a small town in Northwest Washington and saw a lot of people in the rural community there. And then when I came to Olympia, we serve a very rural area. Many of our patients come from the Olympic Peninsula, Southwest Washington. This particular work, though similar to what Jeanne and Karl said, it found me. I got called by the director of the Washington Department of Health’s Office of Rural Health.

She said, Gregg, I’m thinking about starting a rural palliative care initiative. What do you think? I said, it’s a great idea. And she said, good, because you’re going to be my medical director. And that was in 2015. And so I’ve been doing this work now for 10 years.

Eric 06:19

Wow. And then when we think about, like, rural palliative care, what does that look like? Is that just the same thing we do in urban palliative care?

Gregg 06:29

Adie, I’d love to hear your take.

Adie 06:32

Well, no, it doesn’t look anything like urban palliative care.

Eric 06:37

Why not?

Adie 06:39

And everybody jump in with me about this and what seen. But basically, Gregg and I joke. We call it the MacGyvers of healthcare, that people cobble together whatever is needed to be done in a community to make it happen. And people often in urban settings would never consider doing the things that a nurse does or a CNA does in a rural area. People don’t stay in their lanes in rural communities, and they can’t because the services that we provide take for granted in the urban setting are not available in rural communities.

Gregg 07:13

Yeah, I think one of the really unique attributes is, well, you’ve heard the expression, if you’ve seen one palliative care program, you’ve seen one palliative care program. But the champions in the rural communities are so widely variable. It’s commonly a nurse, sometimes it’s a small town family doctor, sometimes it’s a hospital pharmacist, sometimes it’s a community health worker. And the champions are so crucial because they’re the ones who know what exists in the community. And if they’re going to MacGyver, they know how they can MacGyver things to make it work.

Eric 07:46

We may have to explain MacGyver to the younger listeners.

Alex 07:48

Oh, boy.

Karl 07:50

Dean Anderson, anyone? Free hair. I’ll jump in just to say that it’s so variable. And the thing that really unites rural sites is their resilience, their resourcefulness, the MacGyverness of it all, to sort of figure out how to make high quality specialty palliative care work for their community. They know everybody in the community. And so when we think about providing that care, it’s so personal, which kind of wild because when we’re. We’re doing a lot by telehealth, which doesn’t seem so personal. But it’s really the connections with champions where they are that makes it work.

Eric 08:28

And Karl, can I ask you. Yeah, go ahead, Jeanne, before I ask Karl a follow up question.

Jeanie 08:33

You know, I was going to say, to add to what Karl is saying, I think he’s right that it’s so variable. And what we can really do is leverage the strengths of that particular community, what’s important for them and that organization, and then align with it so that we can lift them to something where we can build something, we can help folks to build something that becomes sustainable in that community and is high quality specialty level palliative care.

Eric 09:01

Jeanne, that brings up attention though, in palliative care currently is this idea of like, we need some standardization of a palliative care. So when we say somebody’s getting palliative care, like, we have some sense of exactly what that that means versus this tension about making care very individual for a particular person or particular community and delivering the right thing to the right person at the right time and the right amount. Do you think there’s that tension here?

Jeanie 09:29

It exists everywhere. Absolutely. And I think that’s where, if you hear each program that everybody’s involved in, it looks very different and it’s tailoring to that need for that particular community. So a lot of things are going to be more generalized palliative care and some things are going to be more at that specialty level.

Alex 09:47

Can I ask you a question? Can I go philosophical here for a moment? If you could bear with me? I don’t want to derail. I know Eric has a long list of questions. Okay. All right. So I was fortunate to train at the Brigham in Boston where Paul Farmer was a physician. And many of you, our listeners have probably heard of Paul Farmer, you know, started this worldwide movement to improve access to life saving medications that really changed the landscape of, and a public health approach to how we treat diseases like hiv, tuberculosis worldwide.

And he, I remember hearing him talk about, like, how he would go take, you know, antivirals from the pharmacy at the Brigham, sneak them in his suitcase and then go off to like Haiti or other places because he believed firmly that the standard of care at, you know, the best hospitals in Boston should be the standard of care everywhere around the world and everybody should have access to the treatment. So you can see where I’m probably heading with this. Right. On the other hand, like, the answer to, like, what should rural palliative care be?

Cannot be the exact same thing as it is in the hospital. And like, I feel this tension in my mind. And some of what, you know, the, the choice that people, sometimes it’s a choice to live in rural areas, and sometimes they simply can’t afford to live in urban areas. And they’d like to, but part of that is that there just aren’t. It’s not realistic to try to impose our urban models of palliative care and the high standards that we hold many of these models too, in terms of like all the components of the interdisciplinary team, et cetera, on these rural environments. Can anybody help me out of this conundrum?

Adie 11:27

Well, Gregg and I often talk about our takeaway is humility. When we approach these communities, the last thing they want is our urban wisdom. And we have a colleague who always says that the folks in a rural community have a PhD in their community. And so part of our learning is from their PhD and how do we meld what you’re saying about standards and wanting the domains covered and how do we do it? But it may be covered by someone that we don’t anticipate. Gregg talked about a champion. One of the champions in rural community was the chaplain and moved to tremendously integrated team. So it’s not that we’re lowering the standards, but maybe we’re changing who we think delivers it in a rural community.

Gregg 12:15

Well, piggyback on that. To comment that one of the things we do whenever a new community joins the rural palliative care initiative, and we’re up to about 20 communities now, not all of them are as active because their champion moved on. But we first do an asset and gap analysis. We look to see what does the community have that can help fill in the space.

And then we do a lot of virtual support. So many of the folks that live and work in the community will not have any sort of specialty certification in palliative care, but they have access to a full specialty interdisciplinary team in multiple ways through online case consultations that we do regularly, through open office hours that we do regularly, and through individualized consultation for the community. And so some of the, you know, if I think about the national consensus project delivery, you know, what is the model supposed to look like and what are the standards? Some of that will be done on site, locally, some of it’s going to be virtual.

Eric 13:12

And we’ll have a link to the NCP standards as we talk about them. This won’t be a podcast on, but it sounds like, you know, you can potentially like, why not both, why not have these experts in their community, but also have access to highly trained, specialized palliative care? Is that what I’m hearing?

Gregg 13:29

Yeah, I think so.

Eric 13:32

Karl, you want to say something?

Karl 13:34

Absolutely. Oral palliative care is the epitome of personalized medicine. And when I say that, I mean exactly what you’re talking about. Alex and Eric, is like this melding of that local knowledge with resources of the big city. I think something that is debatable in terms of approach is taking a big city expectation and putting it on a rural community. I think that’s not the way to go. I think it needs to come, as one of our colleagues says, from the bedside up, not from the spreadsheet down. We need to be in the communities that we want to build and serve first. They need a big seat at the table or else it’s going to fail.

Jeanie 14:19

And I would add to that. I strongly believe there has to have local integration. So we’re not bringing a program and saying this is what needs to happen. And this is, you know, it’s now reliant on the program that we are bringing to them. But it’s something that we have integrated. We are part of their program, and if anything, we are. We’re enhancing it, but it’s not something that’s gonna be reliant on us. So that local integration, I think is key for many reasons. You know, it helps to cover the buy in part, the sustainability part, all those things. And people in rural areas especially, they wanna be treated by their own.

Adie 15:03

Absolutely.

Eric 15:04

I got a question. Karl mentioned earlier on that he got into this cause he was also really interested in equity. Is rural palliative care and rural health and equity issue.

Gregg 15:17

Absolutely.

Adie 15:18

You’re talking to a social worker here, so. Yeah, absolutely.

Eric 15:21

Why?

Adie 15:23

Why is it an equity issue? Because, you know, I don’t believe healthcare should be based on your zip code. And rural zip codes are underserved in so many ways, both in terms of having access to palliative care, having timely referrals. Now we’re seeing dramatic cutbacks, disproportionate number of Medicare, Medicaid patients, aging population, educational disparity. I mean, I could just babble on and off and off, but you know, to have lower income and have your closest palliative specialist be an hour’s drive away with the cost of gas, that’s an equity issue.

Gregg 16:06

Adie has a series of slides she uses where she talks about health disparity, but it’s despair in rural communities. And that goes beyond palliative care, access to resources in general. When you look at mortality rates, morbidity rates, things of that nature in the rural health Setting, it’s significantly worse than it is in urban settings.

Eric 16:28

Higher suicide rates, higher mortality rates, higher disability rates, lower socioeconomic status. The list goes on and on. Which is really interesting because what, one in five Americans live in more rural.

Karl 16:41

Yeah, absolutely. Right.

Eric 16:43

And we usually don’t think about that. When we think about we hear the word equity.

Karl 16:47

Right. Or inequity.

Alex 16:49

Yeah.

Karl 16:50

The needs, especially palliative care, appropriate patients, those with serious illness are similar to patients in urban areas, but they’re also different.

Eric 16:59

How so?

Karl 17:00

Well, I want to hear from Jeanie and A.D. Gregg. What do you guys think? I will say that it’s meeting that patient where they are. They need someone that understands who they are in a way, you know, because I think being not from a rural area, I’m from the suburbs of Philadelphia myself. It’s taken me a long time to sort of understand like what. How to sort of communicate serious illness communication with patients in a rural area have a different background than I do. Right. So I’ll just start off by saying the needs of patients in a rural area. They need someone that speaks their language, in a sense, and understands where they’re coming from rather than coming down from the ivory tower.

Eric 17:43

Oh, yeah, I got a question, I got a question on that. So this is kind of reminds me of like age friendly health care or like, you know, the work that we do in geriatrics to minimize the harms of hospitalization at one point. Like, yeah, like older adults, we need to do this stuff. But man, like not waking somebody else at midnight up for a lab test if they don’t need it should be applied to everybody. Like, how much of this is really a rural versus urban thing versus saying no, this is the type of individualized care. It doesn’t matter where you live.

Everything you just said seems like we should be doing that for everybody because we’re going into other people. Like, it could be about somebody’s culture, background. Like all of these, like even micro environments in an urban setting matters too. How much of this is just we should just be doing it flat out for everybody versus just, you know, it matters more. So in rural settings.

Adie 18:40

Well, it should be flat out, but I worry that the finances aren’t there for rural communities. And so when we talk about how we address those equity issues, I feel like the rural communities that we serve are the Cinderellas and tend to get the leftovers. And we have one nurse, you know, when. Karl, to answer your question, I was thinking about someone who understands them. We worked with a nurse who on a hybrid Model Gregg. And remember, she would say, oh, I dated his son for prom. Oh, I barrel raced with her in high school. And you know, we can’t offer that in the city.

Gregg 19:23

I would say that, Eric, it’s more of a yes and rather than an either or yes. Everybody ought to be given that same quality of care. But the element that’s unique in rural settings is often a combination of geography and culture. Some of the cohorts we work with have a very strong tribal presence. And you need to work with the tribal elders or somebody that’s has an expertise in that culture, that community, if you’re going to meet needs properly or you’re going to come with a model that doesn’t fit the community you’re trying to serve.

And so recognizing those things, AD and I also learned when we were doing direct telehealth to some critical access hospital how important the connection with the land is for many rural residents. They want to be on their ranch. They don’t want to be transported to another hospital in a larger community. And we found that we saved a lot of resources by not transferring people when they didn’t need to be. But more importantly, they didn’t want to be transferred. They wanted to be cared for in their home community by people they know. And so if we were able to support them in a way that that was possible, it made a meaningful difference in their quality of care and the

Eric 20:33

quality of life, which I can imagine that you guys, when you’re putting together these, you know, initiatives, how to create palliative care in these communities, there is a lot of challenges. I can imagine one of them too. Like, I want to take care of my community. And like, one challenge is rural hospitals are closing left to right.

Alex 20:54

Yeah, it’s terrible.

Eric 20:56

Maybe we just go around like, each. I’d love to hear from each of you, like, what are the biggest challenges that you are seeing and you’re facing right now delivering rural palliative care today. Today. Jeanie, I’m going to start off with you thoughts.

Jeanie 21:10

I think it’s probably outside of the hospital setting and reaching those folks in their home setting. And I don’t know that it’s any different from today than when we started the program years back with, you know, a lot of the barriers are that it’s distance, right? People just live so far away that, number one, trying to drive to people becomes impractical. Number two, trying to do tele can become impractical because people don’t have, you know, access to Internet or cell phones or whatever that May be. So those things, I think still exist.

Eric 21:44

So big digital divide there.

Jeanie 21:46

There’s a huge digital digital divide that was before and still is there.

Gregg 21:52

One of our communities recently started a project where they use satellite phones because it’s in a mountainous area where they often don’t have Internet. They don’t even have good cell service. And so people will go out with a satellite phone and then they can set up zoom meetings with specialists, primary care from their home doing that. But the windshield time that Jeanne referenced is a big deal in the rural settings. One of our communities was the hospice desert.

Even though there was a hospice that had a certificate of need to serve them, they were over an hour’s drive from the office and they just didn’t have the staffing. So their, their community had no access to hospice until a couple of weeks ago when they got something set up finally. That was really a direct result of their work through the rural palliative care initiative.

Eric 22:34

Yeah.

Alex 22:35

And sometimes we discharge patients to rural areas of California and they’re cared for by all volunteer hospices. Yeah, yeah. So different, sort of very different from the hospice that we may be familiar with or our listeners who practice in urban or suburban settings may be familiar with.

Gregg 22:52

Well, and one real advantage the volunteer hospices have is they’re not constrained by a lot of the Medicare regulations. So the six month prognosis concurrent care, those are things that volunteer hospices can get around in ways that Medicare certified hospices cannot.

Alex 23:08

Yeah, that’s great. Okay. So we’ve heard From Jeanne and Gregg, 80 Karl challenges.

Karl 23:14

Well, you know, Jeanne, you said something really interesting and it’s true. In our system too, transitions of care are a real challenge. We have been able to set up our inpatient telepalliative service across nine hospitals within our system, even between two states, Pennsylvania and New York. But I’ll tell you where we struggle is after we see the patient give our recommendations, they’re feeling good, the pain’s controlled, everybody’s happy, the primary team locally is happy. What do we do with the patient after that?

Because it’s really hard to get people into the clinic in urban areas for sure. But like, unfortunately, we’ve experienced people just lost a follow up. It seems very hard for the digital divide reasons to reach the people after they leave the hospital. I think it’s an infrastructure issue, to be honest with you, and lack of resources, which we’ve already touched on.

Eric 24:03

Even with telehealth, it’s hard to.

Karl 24:07

It still is. It still is. Because despite all our efforts to Set the appointment before they leave the hospital, build that trusting relationship. They understand what specialty palliative care is and is not right. They’re not able really to, for whatever reason, and we’re looking into it. Come to their outpatient appointment via telehealth. Yeah, it’s multifactorial, like so many things. But it’s really a challenge.

Jeanie 24:31

Think about when you’re driving your car and you’re going through some kind of rural area and you’re watching your phone and you’re, you know, your bars go down and down and down. And there’s one part where you’re just not going to get any bars. You’re not going to get through on your cell phone no matter what, until some sporadic space where it comes up again. And that’s temporary.

Alex 24:50

Yeah, yeah.

Eric 24:51

80.

Alex 24:52

How about. Oh, go ahead, Gregg.

Gregg 24:53

I was just gonna say I was doing a hospice home visit a few years ago, that I needed to call the home office and I had to drive three miles before I could get reception.

Alex 25:01

Oh, boy. Yeah. Ad I wonder if we could, if you have, you know, what you have to add. And I also wonder if you could comment on that. You’ve talked about the strengths of the social fabric in urban environments and that a lot of communities, people still know each other and you care for your neighbors. But there’s also a flip side to that, isn’t there? That there are often many people who are living in rural areas who are very socially isolated, lonely and a long way from friends and family.

Adie 25:31

And sometimes end of rotors where they move there intentionally so they’re not bothered by people. And so oftentimes we’ll see veterans who we had one critical access hospital director who says, you know, we don’t need palliative care until we need it. And for these folks who have lived a life of running the show, their own way to interface with the hospital in a given moment suddenly be thrown into an environment where we’re asking them to engage with us.

And how do we navigate that? Ethically, I think, is a very interesting conversation for rural communities. But, Karl, what you said really raised a question for me, which is, I think how do we help urban palliative providers write discharge plans that are accessible for rural patients when they go back to their communities? Because oftentimes they’ll go, oh, follow up with this, follow up with this, follow up with this. But it’s either so hard to do or it’s not even available. How do we help each other do that?

Alex 26:33

That’s good.

Karl 26:33

Oh, you want me to answer that,

Gregg 26:34

Andy, we want you to solve that

Alex 26:36

problem, Karl, right now.

Karl 26:38

All right, so on the fly, let me give you the answer. I think that I don’t have the answer and I don’t know that anyone does. What I will say is that it takes a village. We cannot put the responsibility on that inpatient hospitalist or that surgeon or that whoever is discharging the patient figure it all out themselves. Right. More and more in medicine, we’re seeing team based collaborative care. And I think that approach, I could say, is likely the answer. What that looks like right now, I couldn’t say.

Alex 27:08

Yeah, you know, I’ll say that working with trainees in the hospital who are largely right. Our residencies still train mostly people in the hospital. Right. That’s the setting which they. They don’t do as lot of outpatient care, much less going into people’s homes, much less like going out to rural areas into people’s homes. And so one of the pushbacks I often get from the resident trainees, we’re like, you know, working and training at the same time is I can’t imagine discharging this person to this rural area without all of these supports which, you know, they’re used to having.

And it feels like a ethical, like, moral dilemma for them. Like they feel like they are potentially doing harm to this patient, jeopardizing their safety by sending them home to die on their porch with their dog without the support of X, Y and Z. And, you know, a shoestring volunteer hospice. I wonder if you’ve encountered this and whether that resonates with you.

Adie 28:07

Isn’t that an urban bias, though, that we think about, oh, the poor folks who live in the rural communities? Because we had a nurse who went to a coffee stand to get her morning coffee and they gave her two coffees. One was for her and one was for the EMS call center director who. Who they knew before the nurse knew had been hospitalized with a recurrence of her cancer. And what she said to Gregg and myself was, when an illness happens in rural community, it doesn’t just happen to the patient, it happens to the entire community. So, you know, when your residents say, oh, how do I send them back to this desert? To say, it’s a different kind of experience. Put these rural floats.

Karl 28:56

That’s great.

Jeanie 28:57

I think that’s where we see people step up, right. When people say, we care for our own. Some of the most remarkable stories you can have is when you’ve communicated and collaborated with folks in rural areas about a discharge plan like you’re talking about. And people will come up and take the bull by the reins and move forward. They are going to do things that they don’t normally do, but they’re going to do what’s needed for that patient to make sure that they’re receiving the best care.

Gregg 29:26

And I’m going to come back to a comment ad made earlier about humility. We need to understand that there’s a lot we don’t know. And so setting up a discharge plan from an urban center to a rural community, we need to ask questions. What. What are the strengths in your community and how can we leverage those to help you get your needs met? The best possible.

Eric 29:48

Yeah. And I can also imagine, just like in every community, there’s variability. There are people who are shunned by their community or don’t have that interaction to their community or who are living farther away. And I don’t have those social connections that can make that happen. Is that what you see too?

Gregg 30:05

Occasionally? A lot of the case consultations we get in our regular work with the rural palliative care initiative are community based. And many of them are really chronic, complex disease management cases, more than a classical palliative care case. And frequently there are people that have mental health issues, housing issues. And it’s like in any setting, it’s like when I just don’t know what to do. What am I gonna do? I’m gonna call palliative care. So we get a lot of those cases where the primary care has done a remarkable amount of work. They’ve done interprofessional work with social work, pharmacy and others. But they’re just at that point where it’s like, now what are we going to do? And so let’s see what the palliative care folks can offer.

Eric 30:52

So I’d love to hear from each of you too. We were talking about the challenges. Maybe each of it could be one of your own projects, another project. You’re seeing like one project that or solution to delivering palliative care that you just love again, could be your own, could be another one. So Ad I’m going to start off with you.

Adie 31:10

EMS involvement. We have communities in Washington that are using their EMTs as part of their palliative teams. It is amazing what they do post discharge. They’re trusted first of all, because oftentimes they’ve been there multiple times to pick up someone who’s fallen. So this is a familiar face in the community. They go and they do a checkup post discharge and they participate in the huddles for palliative care in these communities. Sometimes they deliver Meals on Wheels. It is a beautiful marriage.

Eric 31:43

How is that paid for?

Adie 31:46

Good question. Well, in one community, the hospital owns their EMS service and they see it in terms of reduced trips back to the ED and holding patients on. So you know, when they do the numbers, they can balance it that way.

Gregg 32:02

Yeah, tell them the grabber story ad

Jeanie 32:04

okay, the grabber story.

Adie 32:05

We had one EMS who kept getting called to pick up pickup kept coming repeatedly. But what she, she wasn’t down. It was her remote control that she couldn’t figure out how to get to. And she just was calling the EMS to pick up her remote control for her. So the EMT went to the hardware store, bought a grabber for $25 and the calls stopped.

Alex 32:30

I love it. And also we’ll just mentioned that we had Carmen and Katie Quatman, orthopedic surgeon, her sister’s a physical therapist at Ohio State, talk on our podcast about how they work with emergency medical services to integrate geriatric care into patients home settings, including like, you know, putting in grab bar shower chairs, tacking down the carpet, that sort of thing. And the EMS providers absolutely loved it because they’re like, I can’t believe I, I just have to go back to their house again and again and again. I can’t do anything. Now they can do something. So I love that this is happening in palliative care too.

Eric 33:07

Okay, Gregg, what’s one thing that you’ve seen that you’re all wow.

Gregg 33:11

We have a program in Southeast Washington that has really integrated nurse practitioner with some palliative care background into their chronic disease management model. And it allows billing and different codes. It makes it a more financially sustainable model, but it also broadens the reach into the primary care space more effectively.

And they’ve ended up seeing over a three year period, a dramatic reduction in the ED visits and hospitalizations for people that are a part of their palliative care team now. And that reduction grew year by year. So as the team matured, they had a greater impact on prevention of ED visits and hospitalizations. But yeah, that chronic disease management integration I’ve been really impressed with.

Eric 33:55

That’s great, Jeanne.

Jeanie 33:58

I think that for the program that we helped to develop, one of the things that we knew from the start that we wanted to do was for it to be eventually a self sustaining program. And we didn’t know how when we first started it. And over time it kind of became clear of how that happened. And it’s something that I think is really impressive. And if folks aren’t aware, they should be aware.

Eric 34:19

What’s this program?

Jeanie 34:20

So the program that I’m talking about is at Valley View Hospital in the mountains of Colorado. But the program that I’m talking about that helped to make it sustainable is the University of Colorado Master’s of Science in Palliative Care, which is an interprofessional program for folks to be able to have primarily online training to become community specialists.

And there is now a related now ACDME approved community fellowship program in hospice and palliative medicine for physicians where it’s an alternative pathway for physicians to become board certified where they can train in their community home setting so they don’t have to leave. It’s geared for folks that are mid career and so they would be mid career fellows.

Eric 35:07

So they don’t have to do they don’t have to round with an inpatient palliative care specialty team at University of Colorado.

Jeanie 35:14

They don’t have to move. They don’t have to stop working where they’re at. They continue to work at their local hospital or whatever that may be their local setting and have their training over years during that time where they can then be eligible to sit for the boards in hospice and palliative medicine. So you can now get specialists in areas where you’re normally it’s really hard to get a specialist and it’s hard to recruit specialists.

Eric 35:40

What’s that program called for our listeners if they’re interested in learning more about it?

Jeanie 35:44

So it’s the University of Colorado Master’s of Science in Palliative Care program and the related community Hospice and Palliative Medicine Fellowship program.

Eric 35:52

And we’ll have links to both of those.

Alex 35:54

I would imagine Pachita, if it were passed, would help with this issue as well.

Eric 35:59

What’s Pachita? Is that an animal?

Alex 36:00

What’s that? Pachita? Can somebody help me out here?

Gregg 36:03

Palliative Care and Hospice Education and Training Act. It’s a bill that’s been heavily supported by the American Academy of Hospice and Palliative Medicine. It actually passed out of a House committee in early 2020 and was going to be heard on the more broadly when the pandemic hit that just hasn’t gotten back the same level of traction since then. And it works to provide research, education and public awareness for palliative care.

Alex 36:31

And is anything in there about rural palliative care in Pachita?

Gregg 36:35

I don’t recall anything specific to rural palliative care.

Adie 36:38

Okay.

Alex 36:38

All right, thanks.

Eric 36:39

All right, Karl, what’s yours so mine

Karl 36:43

is a program we had here between 2020 and 2022 called the Tele Goals of Care Pause. And it was the AI initiative I came here to build. Fantastic. Providing tele palliative care to critically ill patients in rural emergency rooms prior to transfer. We were not blocking transfers, not rationing care. What we were doing was ensuring goal concordant care for critically ill patients before they got on the chopper.

You know, before they got on the chopper and got so far away from their communities. We have data and found that just like we were talking about today too. Like people want to stay on the land, they want to stay where they are and they don’t necessarily want to be intubated. Right. They don’t want to go to the Bay Quaternary center for all that care. They would rather knowing what the best case, worst case, most likely scenarios are right there in the emergency room being clear about that.

Eric 37:39

So is that an AI case finding and then specialty telepalliative care into those rural hospitals?

Karl 37:45

Correct. Briefly, it was a model that was built here at UWPMC to identify mortality risk after transfer, validated, published and we use that algorithm to identify patients in these emergency rooms. We provided 24, 7 telepalliative care at the point of service right there. And within less than 25 minutes conversation, we’re able to have about a 2/3 reduction transfer, but importantly 94% goal concordant assurance.

Eric 38:15

It sounds amazing. Karl, why are you saying this in past tense?

Karl 38:21

That’s another episode.

Karl 38:26

It has to do with, I think, implementation and something that is often said in our field, that the impact of specialty palliative care is directly proportional to the resources allocated.

Eric 38:39

Yeah. And it sounds like the resources allocated to a rural palliative care is minuscule.

Karl 38:44

Covid overshadowed it at the time. Yeah. Yep.

Gregg 38:47

Did somebody say equity?

Alex 38:49

Yeah,

Gregg 38:52

Well, I was just going to quickly call out too while we’re talking about programs that work is I want to acknowledge some of the work done by like Chris Piramelli in Alaska with a Project Echo and some really good work. Alaska, which is not merely rural, but largely frontier. Marie Bakitis and the team at UAB who have done some really well validated work in rural palliative care. Michael Fratkin in Northern California with Resolution Care. Just wanted to call some names out there.

Eric 39:19

There are huge leaders in this field.

Alex 39:22

Yeah, yeah.

Eric 39:22

I can you briefly also describe because we’ve talked about this initiative that you do ad. What is this initiative?

Alex 39:31

In a nutshell, the Washington State Rural Palliative Care Initiative.

Adie 39:35

What is that Gregg, jump in at any point. This is a model for rural communities. We have 20 at this point. It is voluntary participation. And the foundational principle is Learning Action Network lan, where everybody teaches, everybody learns. We mentor each other. And so through a variety of ways that we can gather people together via zoom, they mentor each other, they offer suggestions. There are two paid consultants, Gregg being one and I’m the other one. And it’s offered through the state Office of Rural Health.

Gregg 40:13

Gregg, just yesterday we had our regularly scheduled open office hours, and one of the folks in Forks, the Twilight community, was presenting a case of a guy that they couldn’t find a discharge plan for. And somebody from an hour away in Port Angeles actually brought up a specific facility that had changed management, and she said, I think this would be absolutely perfect for him. And so we may have found a discharge plan based on that.

We do monthly case consultations where we have physicians, social work nurse, chaplain and pharmacist, and people can present cases. It’s a Project Echo like model, but we don’t have formal didactic, so we often jokingly call it Project Echo Light. Um, and then we have individualized consultations. One team set up a consult with AD and me when they were going to do a home ventilator discontinuation on a guy at then stage als. And we were able to walk the nurse and a nurse practitioner involved in that case through a lot of things that would’ve been new to them because they just had. Didn’t have that type of experience. And we do some didactics, but it’s more individualized and personalized attention.

Alex 41:23

Can we do a lightning round?

Eric 41:25

Go ahead.

Adie 41:25

Just one sentence. When you talk about workforce shortages, it’s the isolation of the rural providers that also contributes to them wanting to go to an urban center. We had one nurse say to us that when I’m sitting at the kitchen table by myself charting, at the end of the day, it’s comforting to know there’s someone across the state doing exactly the same thing. And I can call her.

Alex 41:46

That’s great. Yeah. I wonder if we could do lightning round because we’re running out of time about policy changes you would love to see. Could be changes like the Medicare hospice benefit, changes to telehealth.

Eric 42:00

You got a magic wand.

Alex 42:01

Reimbursement, whatever you want. Anything’s on the table. Could we go around? You have magic wand.

Eric 42:07

You can only use it once.

Alex 42:08

Policy change, you know, Pachita, anything. All right. Karl, can we start with you?

Karl 42:14

Of course. I would love to get off this hamster wheel of are we going to make telehealth reimbursement and parody a law or not? So I would love some confidence and having telehealth coverage and reimbursement parity be written into law so we’re not going through these checkpoints. I know a lot of folks had a lot of great, great, great ideas, but they’re afraid that they’re going to lose reimbursement at some point in the future. So they’re not building it. Yeah. So we need steady reimbursement that we don’t have to worry is going to go away.

Eric 42:47

Wonderful. Does it need to be parity? Like there’s less resources. Right. You don’t, you don’t need your, your, your clinic space. You don’t need your clinic stuff.

Karl 42:59

Listen, equity. Right. We should not necessarily downgrade or think that telehealth is any less effective.

Eric 43:06

Yeah.

Karl 43:06

For patients in rural areas, there’s absolutely a need to bolster the dose of what’s in tele palliative care with a full complement of ibt.

Eric 43:16

Wonderful. Adie your magic wand.

Adie 43:19

I think right now what’s just on the table are all this rural health transformation funding that is supposed to make up for the beautiful bill deficits in rural communities. And I want a palliative representative at every decision discussion on those conversations about how that money should be spent.

Eric 43:38

Wonderful. Jeanie.

Jeanie 43:41

I think in addition to what Karl’s saying also in 80, that being able to have reimbursement for community palliative care, community at the home setting, having palliative care recognized as something that people can bill for and for different disciplines.

Eric 43:58

I’m going to throw in another thing because I’m going to use part of your magic wand. I think more people should be thinking about how do we get rural people, people from rural backgrounds, rurally trained into palliative care fellowships. And that’s why I really love what you’re doing in Colorado, Jeanie.

Gregg 44:12

Gregg, first off, let me just mention, please post the link to Stratus Health and some of the work they’ve done on rural community based palliative care.

Eric 44:21

What is Stratus Health?

Gregg 44:22

Stratus Health. And I think I sent that to Alex yesterday, but I can send it if you need it. My magic wand would be to completely revamp the Medicare hospice benefit, get rid of the six month prognosis, make sure the entire interdisciplinary team is fully covered and just provide high quality, seamless integration of palliative care from the time of serious illness diagnosis through death, and get rid of the hoops. We have to jump through the regulatory

Eric 44:48

really taking this magic wand.

Alex 44:52

Magic wand is now empty.

Eric 44:59

Well, I want to thank all of you for joining us, but before we end, I think we got a little bit more of that. What’s the song?

Alex 45:04

Out in the country.

Alex 45:13

(singing)

Eric 45:58

Jeanie, Gregg, Karl, Adie, thank you for joining us on this podcast.

Gregg 46:03

Thank you for allowing us to be a part of it.

Jeanie 46:04

Thank you.

Adie 46:04

Thank you

Eric 46:05

Thanks for sharing your time and thank you to all of our listeners for your continued support.

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