Demystifying the Role of HHS and ASPE in Guiding Federal Aging Policy and Priorities with Dr. Tisamarie Sherry

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are delighted to welcome Tisa Sherry, who is a health economist and general internist, and is deputy assistant secretary in the Office of Behavioral Health, Disability, and Aging Policy in the Office of the Assistant Secretary for Planning and Evaluation. Welcome to the GeriPal podcast, Tisa.

Tisa: Thank you Alex, Eric, and Ashwin. It’s wonderful to be here today.

Alex: And, as Tisa mentioned, we have Ashwin Kotwal, who’s a frequent guest on this podcast and will be a guest host today. And Ashwin is a geriatrician palliative care researcher at UCSF in the division of geriatrics. Welcome back to GeriPal podcast Ashwin.

Ashwin: Thanks for having me.

Eric: I think that was the longest title that we’ve had on this show, and my first question is going to be, what the heck did that mean? But before we get into that, Tisa, do you have a song request for Alex?

Tisa: So yes, I do have a song request. It is the classic “With a Little Help from My Friends” by the Beatles.

Alex: And why did you choose…

Eric: Why did you choose that song?

Tisa: So I chose it because I think the spirit of teamwork and collaboration that it describes really captures both what I love so much about my role at ASPE, and Eric to get to your first question about all of those words being very, very long, that’s one helpful abbreviation. So we say ASPE as short for the Office of the Assistant Secretary for Planning and Evaluation. So it captures one of the things I love best about that work, how we interface with all of our other colleagues across HHS, and also how we do so with other federal partners and through our work implementing the National Alzheimer’s Project Act, how we also do that with a much broader set of stakeholders outside the federal government. And I think it’s really important because for the policy issues that we’re going to talk about related to older adults, we really need a team approach and an all hands on deck coordinated collaborative strategy to move policy forward.

Alex: Great. Well here’s a little bit. I’m going to do a little more Joe Cocker style just for fun. Here we go.

Tisa: That’s good too.

Alex: (singing)

I thought it was appropriate, “What would you do if I sang out of tune?” I sing out of tune all the time on this podcast. It’s part of the joy of the podcast.

Eric: Okay. Tisa, I’m going to start off. You’re a deputy assistant secretary Office of Behavioral Health, Disability, and Aging Policy in ASPE. What is as ASPE?

Tisa: Great question. So, ASPE is a policy research and advising office that sits within the Office of the Secretary at HHS, the Department of Health and Human Services. And so in some ways you can think of us as the secretary’s in-house policy research and advising group. So our roles are to conduct policy research, advise, and consult with the secretary on policy development, but also, since HHS is such an enormous federal department, to coordinate policy making across all of the various agencies within HHS to make sure that we are aligned speaking with one voice, and doing so being more effective at moving the agenda forward.

Eric: And can I ask, most of our listeners are practitioners and geriatrics in palliative care, lots of different types of healthcare providers. You are a healthcare provider, right? You had a primary care practice. Do you still do?

Tisa: I don’t currently, but yes, I previously did adult primary care.

Eric: Why did you choose to join ASPE?

Tisa: Well I was very fortunate to get invited to join, so I’m a political appointee at ASPE, but part of the reason that I took the offer was that one, I thought it was a tremendous opportunity to pull in both the insights that I learned from taking care of patients, but also from doing health policy research to try to inform the conversation around key policy issues at what was a really exciting time for policy development. There was a renewed focus on the unique needs of older adults, in particular in the aftermath of the COVID-19 pandemic, and so I thought that this was a really important time in particular, and an exciting opportunity to get involved in contributing but also learning a lot from really tremendous colleagues on this topic. And my interest in background in it more broadly has to do with both my experience as a primary care provider taking care of older adults, but also just observing the experiences of people in my own family.

So I have two grandmothers who are in their nineties, doing really well, living on their own with close family nearby. They’ve had some health issues here and there, but overall they’re really thriving, and it didn’t take much when I was in medical school and in residency to see that is just not the case for everybody else and how fortunate they are and how they’ve been able to have that with the support of a lot of family. And so my goal and motivation is, well, all older adults ought to have access to that if that’s the sort of setting that they want to live in as they get older, but we don’t really have a very robust system in place to assure that, as you and all your listeners well know.

Ashwin: Yeah, it’s so interesting to hear about your personal experiences and how that has informed the work that you do. And I know that you’re also trying to coordinate with all of these different agencies that are in place within HHS and other parts of the government, and I’m wondering if you could take us through the day to day how that works. We saw some mention of the inner-agency coordination that you do, but how do you balance all these different competing concerns and voices?

Tisa: Wow, so it’s a great question. So one of the things that I really, really love about this job is because on a day to day basis it is so varied and there’s so many different ways that we get to engage on policy matters. So it’s hard to say what a typical day looks like, but the range of things that we can cover are meeting with team members to get updates on the research they’re doing, so we have a robust research portfolio. ASPE is divided into several different policy offices, but my office focuses on behavioral health, disability, and aging policy, also including long term care, and then we’re also the point office for policy issues affecting people who are dually eligible for Medicare and Medicaid. And with some of our sister offices in ASPE, we also coordinate housing related activities across HHS, and also the needs of justice involved returning community members. So it’s a really broad array.

Alex: Yeah. Broad. Wow.

Tisa: Yeah, it’s huge. It’s the easy stuff too. But it’s wonderful. It’s such a varied range of really, really interesting, really important topics. Challenging for sure from a policy standpoint, but also areas where I think we have so many opportunities. And so, in a given day, so we have active research in all those areas, so my work can involve meeting with our subject matter experts to hear about what research ideas they have and want to get up and running, what we’re learning from ongoing projects we have in that space, thinking about what are the gaps and how we can push the evidence space further to get information that can really help inform decision making, and then also how we can really translate and disseminate the information we’re leading so far, both amongst our federal partners but externally, to inform decision making. So that’s-

Eric: Can I ask is it possible to give an example of a project that you’re really excited about, something that that’s been done or currently in the works that can help clarify exactly what that is that you’re doing? Because it seems huge.

Tisa: Yeah, so we actually just last week posted a recent set of research projects that I think can encapsulate some of that. So this was a series of different short reports about the impacts of the COVID-19 pandemic on nursing home staffing challenges. And what was interesting about these reports is that we took a mixed methods approach, which involved looking both at quantitative data, look at impacts on staffing in nursing home facilities, but also having conversations with key informants about what sorts of challenges came up to help put the data that we were seeing into context. And through that work, some of the key things that we found were an increasing reliance on contract staff, some differences in staffing challenges across different types of facilities, so facilities with lower star quality ratings, for example. We’re relying more heavily on contract staff and we’re reporting having more trouble getting more staff during the pandemic. Facilities, unfortunately, that were serving a higher share of residents from minority racial and ethnic backgrounds were also reporting greater challenges with addressing the staffing needs that arose during COVID.

So that’s some research that we did that grew out of that, but in terms of how we want to use it, we’ve been sharing it with our partners across HHS. There’s a lot of work underway across the department to just try to figure out how we can better support nursing homes to provide high quality care for residents. One key policy idea that has been proposed and that our colleagues at the Center for Medicare and Medicaid Services are working hard on is figuring out what minimum staffing requirements we might want to be putting in place for nursing homes. So that’s evidence that we can then bring to the conversation and the table as we’re working with our federal partners to see how we can build the strongest, most evidence informed policy.

Alex: Now, can I stick with that for a moment? We did this podcast early in the pandemic with Jim Wright, who was a nursing home director, I think in Virginia, and his nursing home’s just ravaged by COVID, and so many of his contract nurses and staff weren’t allowed to come in, even, because they worked in multiple places. They didn’t want exposed to COVID and then go to other places. So he ended up with his wife who’s a palliative care physician, he’s a geriatrician, doing so much for the patients there. They were the staff. They were the docs. They were delivering meds. They were doing meals. Everything. And then we interviewed him again a couple months ago, and we said, “It’s been like two or three years, what’s changed? What lessons have you learned?”

And I’m just going to quote from his interview, he said, “Well, what happened in the pandemic coming out of it was I felt very energized by all the shortcomings that were exposed, the shortcomings of how we deliver long term care in this country were exposed, so the entire country was focused on how poorly we deliver care for our elders, especially in for-profit facilities. And my conviction was that real change would come from this, and we would all come together, professionals, family members, owners, and operators, finally push through the changes that needed to happen to prevent another pandemic, another 150,000 elders from dying, and then pandemic. Of course, we know that did not happen.” And he was just expressing his disappointment that we had this moment, we had this energy, we had this focus, and we kind of lost the thread, not just kind of, we did, and that huge change didn’t happen.

So I just wonder your thoughts and observations on that health policy change for long-term care is hard, and, here, we are trying, and here’s how we’re trying, and these are the ways in which we try, and we hear you. Thoughts from you about that commentary.

Tisa: Yeah, well, I guess, first I really want to validate the frustration that he’s expressing, which is that yeah, absolutely, things move slowly in all areas of health policy, and long term care policy in particular, which is not the way any of us would want it to be, but is the product of, I think, a couple of things. One is that of course, as we all know, the COVID-19 pandemic shown a light on a system that had been neglected and had received insufficient investment for a very, very long time, and so there is no quick fix to address that.

So, one of the other things that’s interesting about the work we do at ASPE is we do, through the Organization of Economic Cooperation and Development, get to hear from a number of our counterparts in Western Europe about their experience during the COVID-19 pandemic and how they’re trying to approach their long term care systems more broadly. And what’s interesting is that while they’re, I think, doing a bit of a better job than us overall, it’s fair to say, a lot of the core challenges that we experience in the US they experience as well. We have an aging population. We have a lot of inherent challenges in our long-term care financing systems, and everybody is struggling in a way to figure out what is the optimal way to set up a long term care system. Everything has been so health system centric. Is that really the right way to go? But that has to do a lot with how we pay for care in this country.

So I guess the answer is it takes a long time because it’s hard, but also because I think we really want to get it right, and we want to make sure that the changes that we make are informed by the best evidence. So because any change we potentially has pretty significant ramifications, and also can be hard to undo if we get it wrong. An example of that I think comes back to this minimum staffing requirement policy proposals. So that was put out there by the President in the State of the Union, and it’s going to be a while before that gets established, and the reason for that is that our colleagues over at CNS really want to get extensive public input and they want to conduct a study to make sure that whatever requirements we’re putting in place or reform are informed by the best evidence. So I hear him a hundred percent, and we’ll try to keep moving things as quickly as we can.

Alex: Mm-hmm. I hear you. This is tough. On the one hand, I feel like do we really need more evidence before instituting a policy of minimum staffing requirements? It seems to me like, oh this is just so obvious. On the other hand, there have been other obvious examples of we should do this, and when we’ve studied it, it hasn’t worked out to be as obvious as we thought. And there are always unintended consequences to major policy shifts. So I hear that tension in how challenging that is, and that’s the space you’re sitting in. Yeah.

Tisa: Yeah. And it’s also not just should we, but what should it be. Ought it to vary by different types of facilities? Are there situations where we might need to make exceptions? So it’s also that whole set of you decisions that flow from putting in place a policy in terms of how are we actually going to implement it, and how do we take into account all of the diverse views of different stakeholders in this area to make sure that we also have the buy-in and support necessary to move this forward? All of that contributes to taking time, but the hope is that if we’re going to take that time that we get it right.

Ashwin: Yeah, I’m struck by all the different perspectives you all have to incorporate. One of the challenges in geriatrics and palliative care is often we feel like our voices aren’t being heard in many of the policies and decisions that are being made. And these clinical stories over the last few years have just been so powerful, and people have ideas on how to make change. You mentioned trying to get input from stakeholders or these key informants. How do you approach that, and are there opportunities for clinicians to get involved and have a voice in these policy discussions?

Tisa: Yeah. So there are lots of opportunities, thankfully. And we so value the input that we get from practicing clinicians from stakeholders of all types and backgrounds, so I can’t overstate that enough. The voices are so, so important. So a number of ways. So one is that in a lot of our research we actively seek out those perspectives, also increasingly we try to seek out the perspectives of people with lived experience, and so what are we hearing from patients who have been affected by all of the additional challenges in long term care during a COVID-19 pandemic? So there’s an emphasis on our research in having it informed by a wide array of voices. But then there are a number of other activities we undertake where we really try to bring in other perspectives. And so one I’ll highlight is from our work implementing the National Alzheimer’s Project Act, so that’s another one of the really cool things that my office gets to do.

So National Alzheimer’s Project Act was signed into law in 2011. It requires a secretary of HHS to maintain a national plan to address Alzheimer’s disease that we update every year, and then also establish an advisory council on Alzheimer’s research care and services, which is comprised of both federal and non-federal members. And so that advisory council for over a decade has been meeting every three months, and we have not only senior folks from each of our HHS agencies, but also several other federal departments that are involved at the table. But we also have a rotating group of non-federal members who include clinicians, they include researchers, they include other folks who may be working in and/or managing long term care services and supports in communities. They also include caregivers and people with lived experience, so we have people with dementia who serve on the advisory council. And when we have the quarterly meetings, they are fully transparent, so they’re livestreamed to the public. People have the opportunity to call in and make public comment, and then we release the transcripts afterwards.

But that’s one example of a forum in which we bring together voices from really all diverse backgrounds who have a stake in Alzheimer’s disease related care. And it provides a forum for us all to hear from each other and get on the same page, and hopefully make better policy as a result of it. And then one of the other key ways in which people can make their voices heard, which I really encourage all my clinician and researcher colleagues to do because I think we don’t do it enough maybe because we’re not aware that the opportunity exists, but every so often agencies will put out a request for information where we are literally formally soliciting feedback on a potential program or idea.

That’s one thing that’s happened, for example, in the context of the minimum staffing requirement. When we have a new regulation coming out, we do notice some comment rule making. So there’s an opportunity for people to submit public comments. We’d love to hear from clinicians and from researchers as part of that, and that’s actually a really nice way to make your voice known through the process so that we have to listen and we have to incorporate that and take it into account.

Eric: I guess my question is, having commented before, I won’t say on what, but on big policy issues, I was wondering what actually happens with the comments, and how much does it influence decisions when it comes from a single provider versus a large organization or somebody with a lot more power?

Tisa: So I think what we look for are whether there are key themes that are cropping up across the board. So really, I mean, hearing from a large organization, what’s helpful there is that, well, that’s a signal of maybe how their membership thinks, and so we’re hearing that this is a thought or a concern that is pretty consistent across a number of people. So is there strength in numbers? Absolutely. But if we’re hearing the same key themes being articulated across a number of individual comments as well, that’s a signal we definitely pay attention to.

Eric: I’ve also noticed there are a lot more form letters that organizations, patient groups, they encourage their members to fill out. When we think about it, how important is it just to come from your own words versus use an organization or patient groups form letter?

Tisa: That’s a really great question. I’m not sure I know the answer to that.

Eric: Okay.

Ashwin: And then, of course you could just maybe tweet at HHS and ASPE, and that might be the most impactful.

Tisa: You can always tweet, but what we always do tell people is that anything we receive outside of the process, it’s something that people may definitely hear and pay attention to, but it’s not something that we have to formally take into account in the same way. So I always say use the process, and then any other way you want to yell at us, at us, get our attention, feel free.

Alex: So many of our listeners are also researchers, and they’re wondering if there is a way they can direct their research? So Ashwin does research on loneliness and social isolation, and how could he direct his research to have an impact on policy? What kind of research is most likely to have an impact on policy?

Tisa: Well, so the short answer is all of it, and not to exaggerate. So one thing I often wondered before I took this job and was doing research was everybody really care about this? And absolutely, a hundred percent. I mean, I am a believer more than ever in the value and importance of research and informing policy making. We, our leadership are looking for it and relying on it and learning from it all the time. So a lot of the research that I typically see published in peer reviewed journals, so where there is an emphasis on maybe a evaluation of a particular policy change, and not to over generalize, but more often than not the style is, “Well, did this policy work or did not? Did this program work or did it not?” That’s generally the thing that I see published a lot. And is that helpful? Absolutely, especially if it’s done with pretty rigorous methods.

The kind of thing I don’t see done as often in peer reviewed journals, which is really important, which I’d love to see more of, and asking we try to plug this gap a little bit, but I’d love to see more colleagues outside of federal government doing this, is a little bit more of the how. So this program worked. Well, how did you get it to work? Or this program didn’t work. Well, why? So digging a little bit more beneath the surface. Sometimes I think doing that requires getting a little bit more into mixed methods, so what can we understand from what we saw in the quantitative data by actually talking to people who were engaged in this policy? But also trying to understand some of the other factors that influence success or failure, because those are the things that we’re going to have to take into account when we figure out how to take an effective intervention and implement it and scale it up in, frankly, less than perfect circumstances.

So many of the studies that we see carried out in very tightly controlled settings, we know that when we try to bake that into an insurance program or a grant program or something else, we’re not going to necessarily have the same levers to ensure that the intervention was done the way we want. So we’re always trying to figure out what’s the best we can do given some of the policy constraints that we have in place, and we’re figuring out what some of those other factors are that affected success, and also the practicalities of how did you actually get this done would be really helpful to know and to understand. And so from a researcher standpoint, I think some of the things that can help in guiding to pose those questions are, well, ultimately if I have a successful intervention, who’s actually going to be doing it and who’s going to be paying for it, and what do I know about some of the constraints on their end, and what information do I think they’re going to find helpful to be able to do this well?

Alex: Hm. Yeah, okay. Just a follow up question about that, I’ve heard that Health Affairs has an outsized impact on health policy decisions relative to its impact factor, right? Do you read Health Affairs? Do you have a general sense this is true? Is it sitting in people’s offices along with the big major clinical journals or not?

Tisa: I think Health Affairs is very impactful, but so are a number, and we don’t only get our evidence from the peer reviewed literature as well. So there are lots of foundations and other research organizations that put out really excellent reports, some of which get to this gap in the evidence that I think the peer reviewed literature doesn’t always fill that I was talking about in terms of how you actually implement something and get it to work in different contexts. So yes, Health Affairs is very important and impactful, but there are definitely a range of resources that we look to.

Ashwin: Yeah, and I mean you mentioned that health policy can move slowly for older adults. There’s been a lot that’s been happening in these last two years that requires more fast action. I was curious how you’ve struck the balance between thoughtful evidence-based approaches, and being nimble enough to respond to challenges as they come up as the pandemic has unfolded.

Tisa: Well, there are some things that just creep up on you. And we think about this a little bit actually in my office when we do our research planning. We think about what are the long term questions that we really need to invest in because we’re not sure that otherwise a big issue is going to come up and set everyone’s hair on fire and that we’re going to have to address it? And one of those has been how do we strengthen and inform how we re-envision the long term care system, because until COVID, that was unfortunately not something that was on everybody’s radar. So we have that, but then there are always other things that come up a little bit more urgently and emergently, and for those we have to be prepared to act very nimbly, and very quickly pull together the best evidence we have to help brief leadership and inform a decision on it.

And that’s one of the really cool things about ASPE, and it’s one of the many incredible superpowers of the staff who I get to work with that they are incredibly adept that both doing that sort of very deep thinking about where do we need to re-envision this, and where do we need to go long term with? Somebody in leadership needs a briefing on this in two hours because there’s a time sensitive issue that we have to deal with. Now, both based out of my brain and everything I can find very quickly, how do I get them the best evidence to make a really good decision? So they manage to do both of those things incredibly well.

Alex: Mm-hmm. And you’ve touched on two of the major issues that I’m sure all of our listeners would agree need policy attention, which is long term care and supports for older adults and Alzheimer’s disease. And I just wonder what your thoughts are on where we need to go in those areas, what questions we need to have answered that you’re talking about with your ASPE colleagues and thinking about addressing? What is the vision? I mean, we know, for example, from asking older adults, that they want to age in place as much as possible. And I know there’s been a shift in policy to shift funding from supporting institutional long term care towards long term care provided in people’s homes. Thoughts about the direction of that or anything else in the realm of unanswered questions, directions that you’d like to see policy move toward in the area of long term care and care people with Alzheimer’s and other dementias?

Tisa: Yeah. So such a great question. So one thing I’ll say in the long term services and support space is that we’ve made a lot of progress over time in moving more people into home and community based settings for care. So that is wonderful. And that achievement, I think, cannot be understated. But once the real challenges in trying to move that forward has to do with data gaps. So we have more levers in some ways to influence nursing home quality than we do care in home based settings, and that’s for a number of reasons. It has to do, for example, with how those markets are organized, with who pays. So much home care is private pay entirely, and so HHS’s levers are quite limited there. And a related issue is that we also don’t get as much data capture in terms of what’s going on, and so it’s hard to understand where are the pain points and where can we really intervene.

And so one thing that I think would be tremendously helpful for driving forward a policy agenda would be strengthening data collection on home and community based services, and with a particular focus also on workforce. From a policy standpoint, workforce is really the key issue that keeps me up at night and makes me worry in terms of how do we ensure that we have a robust and a more robust long term care system going forward? There again, we know more about the workforce in nursing homes and institutional settings, and we know so much less about people who are providing services and supports in home and community based settings. Well, we’ve got to know more in order for us to figure out what the most promising policy lovers and approaches are. So in long term services and supports, I’d say that’s one key thing that we think a lot about. On the Alzheimer’s side, I think there are a couple areas.

And so we recently celebrated the 10th anniversary of our national plan to address Alzheimer’s disease, and we took that opportunity to step back and say, “What are going to be our real areas of focus moving forward in the next 10 years?” And there were a couple of things that we decided we thought were really important. So one is a real focus on equity and addressing disparities at every stage of the dementia care trajectory. And so I think there’s been a tremendous amount of work that has been done to help us better understand the unfortunately pervasive disparities and access to care and long term services and supports resulting in poor outcomes for people from racial and ethnic minoritized backgrounds when it comes to Alzheimer’s disease, but what are the effective policy solutions to really help us address this? I think that’s one area that we’re particularly interested in.

And then another is that one of the things that has also been cool about this new role is that we hear so much about really innovative work that’s being done at the state and local level to try to address this and to try to pull together the right array of supports to address people’s needs, and so one thing we’re also trying to figure out is how do we, as the federal government, add more value to the great work that’s already happening on the ground? How do we help scale up and support really effective models so that we can take the great work that people are already doing and just amplify it rather than getting in the way. So, and maybe this also gets back to your point, Ashwin, about what the role of the voice of clinicians is, I’d love to hear more about the things that have been tried in different settings and that have worked and that people think have promise, and then we’ll get the word out and we’ll try to figure out how we can help support and scale those models up.

Alex: Mm-hmm. Great answer. Terrific.

Eric: And let’s say we have something that somebody’s doing, how do they get the word out?

Tisa: So there are a number of ways. So, at least in the Alzheimer’s care space, there is the National Alzheimer’s Project Act Advisory Council meeting. So you can reach out to members on the advisory council, let them know about exciting work that you’re doing. And then every three months we’re pulling together that meeting agenda, and we love to highlight and lift up really innovative models that people are using. Also, the department as a whole is always actively reaching out to stakeholders to try to hear and capture more information about what challenges they’re encountering in doing their work, and what are some ideas for innovative solutions, and so our Office of External and Intergovernmental Affairs usually takes the lead in pulling together those convenings, so they’re also a great place to start with. We have HHS regional offices that are also useful point of contact for getting in touch and letting people know what they’re doing. And there’s me. So folks can always reach out to me in this space. I’d love to hear about what you’re working on and figure out how we can help expand that to benefit more older adults.

Alex: I have a question. The UK has a Minister of Loneliness. Shouldn’t the US have a Minister of Loneliness, and shouldn’t that be Ashwin Kotwal, and can you tell Biden?

Tisa: I think you’ve just made the argument right there, Alex. [laughter]

Ashwin: All right, here we go.

Eric: Shouldn’t it be Minister of Anti-Loneliness, because it kind of feels…

Tisa: Well, I guess in this context he would be the Secretary of Anti-Loneliness.

Ashwin: I was going to say, yeah, we don’t use Minister here. [laughter]

Tisa: But yes. Well, Ashwin is obviously the perfect person for that role.

Alex: My other question is whether loneliness and social isolation are on the radar screen of HHS or ASPE.

Tisa: So definitely, and thanks in no small part to Ashwin’s incredible and impactful work in this space. So they definitely are. They’re an interest of ours in ASPE. It’s also a topic that the Surgeon General has spoken on a lot. And so there are others in HHS leadership certainly who care very much about the issue and who have found the research evidence very compelling. I think what we’d love to figure out, and hopefully Ashwin is the guy to get us there, is how do we take the next step based on the great evidence that we’ve received? What are the interventions that are effective in addressing this, and what are some of the opportunities that we might have for supporting those with the federal levers that we have in place for those interventions that are effective. I think that’s definitely an area that we’re interested in thinking about more.

Alex: Okay, so we got to say, because it’s a running thing on this podcast, next time you see Surgeon General Vivek Murthy, please ask him to come on the GeriPal podcast. We’ve tried to get him on for a while. He hasn’t said no yet, but he also hasn’t said yes. So we are working on it. We want everybody, all of our listeners, anybody who knows him, please tell them we’d love to get him on the GeriPal podcast, because we’re determined.

Tisa: Right. I can be your ally on that. [laughter]

Eric: I also realize I should have asked this question before, but for me and probably some of our audience, we keep on mentioning HHS. What is HHS? I know that’s an hour long answer, but how should our audience envision what HHS is and what does it do?

Tisa: So, well, HHS is the lead federal agency on healthcare policy and health systems related issues. And we are comprised of a number of different agencies that carry out various and really widely ranging functions. So the Centers for Medicare and Medicaid Services is probably the agency that is most familiar to people. They administer Medicare and Medicaid, and handle all regulatory and payment matters related to those programs. There’s the Centers for Disease Control, which conducts research, puts in place federal public health guidance. But there are a range of other agencies as well. HRSA, Health Resources and Services Administration, makes grants and investments to support workforce development, also oversees our federally qualified health centers and also HRSA health centers. There’s the Administration on Community Living, which is particularly relevant to listeners for this podcast, administers a range of grants and other programs to help support community living. There’s also a huge side of HHS that is human services, so the Administration on Children and Families, which runs Headstart, for example, and a number of other human services related programs. And I barely scratched the surface. There’s also the FDA-

Eric: From the FDA to CMS. It’s huge.

Tisa: Yes, it’s huge and it’s really varied. Yes.

Eric: And potentially a lot of levers to influence both direct and indirect care, and a lot of friends to bring together. Yeah. Going back to the song, Alex. Wait, before we go into the song, I’m going to give you a magic wand. If you can use that magic wand to change one thing, what would you use that magic wand on?

Tisa: Hm. Well, I think just saying, “Fix long term care,” is probably not specific enough. So a while back I participated in a panel with Bruce Vladeck, who was a former administrator of CMS at that time, Healthcare Financing Authority, and he, I think, summed up a vision for where we might try to go with the long term care system, which really resonated with me. And his argument was that we’re relying really too much on hospitals and healthcare systems to manage something where the majority of care is happening in homes, and as a result, we don’t have a rational payment system for trying to support that since so much payment is tied to healthcare settings. And so he articulated this vision of having it be more regional collaboratives, where a healthcare system is one component, but all of the other systems that touch the lives of older adults, public health, housing, nutrition, transportation also are more empowered and have a more robust key role and we can effectively coordinate resources.

So I think if we could set that up and test that out, I would love to see if that could help move us in a better direction for long term care. It’s not a totally radical concept, right? We tried to do this in other areas of healthcare, and there’s been accountable health communities. We are trying to do this more around pediatric care, and those experiences, we’ve seen mixed results, but I think there may be reason to think that in long term care there could be more promise because so much of care delivery is happening in people’s homes and it’s family members who are providing it. And the current regulatory and payment levers that we have just don’t really get at that in a meaningful way.

Alex: Yeah, Bruce Vladeck’s brilliant. That’s a great summary of that direction. The Institute of Medicine report on, was it End of Life Care in America, something like that? I don’t have the title quite right. Came out maybe six or eight years ago. And one of their key policy recommendations was that Medicare should pay for custodial care, which it currently doesn’t. And I don’t know if that’s something that’s being considered, is on the table at all, but boy, wouldn’t it be great if we had a system healthcare system that paid as much attention to the daily needs of older adults, which are much more around getting help dressing, getting out of bed, bathing, showering, taking your medications, than they are about putting in this new device or that new device?

Tisa: So through consumer self-directed services in Medicaid, we do have a lever to support that to some extent. And people who want their family members to be able to provide that care, can get some financial support from their state Medicaid program with federal matching to support that. But it’s not being done uniformly across all the 50 states, and the scale is very limited relative to the tremendous need.

Ashwin: I had one quick question related to that. The VA does a lot of policies related to that, custodial care, thinking about caregiver services and trying to elevate the role of the caregiver. Is there communication between your group and the VA in thinking about policies and lessons learned from these different health systems?

Tisa: Oh, absolutely. Yes. So the VA is one of our federal partners in the advisory council for Alzheimer’s research care and services. So yeah, they’re a wonderful partner who we love to learn from in all areas of healthcare delivery, but certainly in this area in particular. So some concrete examples of how we’re taking VA lessons and translating them to HHS, so in the past year, the Indian Health Service launched to help geriatric scholars pilot program, which provides this intensive individualized training to healthcare providers who are looking to develop greater competencies in geriatrics. That grew out of the VA pilot program. And again, this gets back to “A Little Help from My Friends”. We are trying to learn from innovative work happening state, local, but also at our federal partner level, and figure out how we can translate it and implement it to the populations that HHS serves.

Eric: Well, with that excellent call back to the song, Alex. You want to give us another verse?

Alex: (singing)

Eric: Thank you, Alex. Tisa, thank you very much for joining us today. That was a great podcast, and thanks for your work you’re doing. Love the song selection. And Ashwin, thanks for joining us as well.

Tisa: Thank you so much for having me.

Ashwin: Thanks Alex and Eric. Thanks Tisa. This was great to talk with you.

Tisa: Yeah.

Eric: In addition, and we want to thank all of our listeners for supporting the GeriPal podcast. If you have a moment, please also go on your favorite podcasting app and rate us, or share us on social media.