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Home-based Palliative Care: Podcast with Brook Calton and Grant Smith




Home-based palliative care is booming.  And with the growth of home-based palliative care come unique struggles and challenges: how can it be financed, what does the ideal team look like (or do you need a team?), retaining clinicians who may feel isolated doing this work, identifying patients who are most likely to benefit.

In this week's podcast we talk about these and other issues with Brook Calton, home-based palliative care physician in the Division of Palliative Medicine at UCSF and Grant Smith, a recent graduate of UCSF's palliative medicine fellowship now faculty at Stanford.

To supplement our podcast, Grant has written a series of thought pieces that flesh out and complement our discussion.  His first reflection was published in the Journal of Palliative Medicine last month.  We will post one additional reflection per day for the next three days.

Reflection #1: posted Friday, Feb 28, 2020
Reflection #2: posted Monday, Mar 02, 2020
Reflection #3: posted Tuesday, Mar 03, 2020


Hope you enjoy my attempt at a Southern drawl while singing!

-@AlexSmithMD



  


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TRANSCRIPT

Eric: Welcome to the GeriPal podcast, this Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we have two people in our studio today.

Alex: We have two people. We have Brook Calton who is the director of home-based palliative care at UCSF. Welcome to the GeriPal podcast Brook.

Brook: Thanks so much for having me.

Alex: And we have Grant, Grant, Grant ... something.

Grant: You got this.

Alex: Grant Smith.

Eric: Are you guys are brothers?

Alex: We are distant long lost cousins. He's from the Tennessee branch of the Smith family.

Grant: Exactly.

Alex: Grant Smith who is a palliative medicine physician at Stanford. He's on loan to Stanford from UCSF. Welcome-

Eric: Do they know that?

Grant: I don't know if that was accurate [laughter]

Alex: I hope nobody from Stanford is listening [laughter]. Welcome to the GeriPal podcast.

Grant: Thank you for having me. Super excited to be here.

Eric: So we're going to be talking about home-based palliative care, but before we get into that topic, do you have a song request for Alex?

Grant: The song we're requesting today is Back Where I Come From by Kenny Chesney.

Alex: And why this song Grant?

Grant: So Kenny grew up and was born and raised in Knoxville, Tennessee, which is also my hometown.

Alex: It's great. And, it's kind of like back where I ... The home, being home.

Grant: Being home.

Alex: Home-based palliative care. The topic, yeah.

Grant: Exactly.

Alex: It comes together.

Alex: [singing] In the town where I was raised. The clock ticks and the cattle graze. Time passed with amazing grace. Back where I come from. You can lie on a riverbank or paint your name on a water tank or miscount all the beers you drank. Back where I come from. Back where I come from, where I'll be when it's said and done. I'm proud as anyone that's where I come from.

Alex: Yeah, that's great. Kenny Chesney's that's our second Kenny Chesney. First was, Old Blue Chair. That was Jeff Williamson on the blood pressure control sprint mine. I had not heard Kenny Chesney before but he's grown on me.

Grant: You're welcome.

Alex: Thank you.

Eric: Okay, so this is our home based palliative care week on GeriPal so we have three of Grant's posts that we just published on Monday, Tuesday and Wednesday of this week on home based palliative care. Grant also just published in January, I believe, a paper for the journal of palliative medicine on home based palliative care. It was a personal reflection and I'm wondering Grant, taking a step back and we'll have links to all of those things on our GeriPal website. How did you get interested in home based palliative care?

Grant: I was really lucky during residency actually to meet Brook and had some opportunities in residency to go do some home visits with patients who were being followed by Brook and the home based palliative care program at UCSF and then as a fellow I wanted to do an elective to learn more and see more. And so my first month of fellowship I spent a month with Brook and also took some time to talk to other providers in the area about home based palliative care to find out more about what was going on in California.

Alex: For the JPM paper, it's called, home is where the heart is and you describe an experience in home based palliative care that that seemed like it was a pretty important experience to you. Do you want to describe it for our audience?

Grant: Yeah. I think one of the most powerful things about going to visit a patient in their home is how that experience can have a huge effect on you and your relationship with the patient. So I talk about, in the reflection piece, how walking into the patient's home really reminded me of my grandfather's makeshift garage workshop and this patient's home had the smell, the feel, the look of my grandfather's garage workshop. And I think that just helps me be present in that experience in a different way than if I were seeing the patient in clinic. Also, seeing the context of the patient's home, it validated his decision making process.

Grant: I just could understand you had all this collateral information about the patient that was just immediate from the smell, the look, everything going on confirmed, always most important to him. And in this case it was about his independence and his home looked that way. And so it was just a really powerful experience to see how a home could help me understand more about my patient and also helped me feel more connected to my patient in a way that I just couldn't get in a clinic visit.

Eric: And Brook, you've been doing home based palliative care since...?

Brook: 2013.

Eric: 2013, so quite a lot of experience in the area. How did you get interested in it?

Brook: I had tossed around when I was a medical trainee, a bunch of different careers and palliative care and oncology, and in primary care and for me, home based palliative care is a lovely blend of all of those three things. We get to care for a lot of patients who have cancer. We get to follow people longitudinally over some number of usually months to many months or even a couple of years. And I get to practice specialty palliative care as well and so for me it feels like a very natural fit. And had also had some experiences during my own residency, doing home visits similar to Grant. And, what a cool way to care for people, like totally old school but super cool and cutting edge in a way now.

Alex: It is cutting edge. This is a relatively new addition to palliative care, this idea of home based palliative care. So 2013 - that's got a leading edge and this was just starting because I still think of it as just starting in 2013 was like seven years ago now.

Brook: Yeah. I think as we all know, palliative care really started in the inpatient setting and grew up there, at least from a specialty palliative care consultant perspective. And then moved into the clinics, particularly starting in oncology clinics and oncology centers. And then I think a natural extension from that. We started moving into the home and I think now, and we'll talk to them, I'm sure about this as well.

Brook: It is something that just makes a lot of sense for everybody. It's a win-win for patients and families who can't get into clinic and feel so grateful that you can see them where they are. It's a win-win for clinicians because I think there's a lot of rewards and job satisfaction that comes with caring for people in their home. And then for potential payers and different payment systems that are becoming even more precedent with value based care, it's a win-win for insurance companies and other people who are trying to manage people's care and expense as well.

Eric: Can we get to thinking about when we say home based palliative care, what do we actually mean by that? Does that look like what it looks like from an inpatient consult service? Does it look like your traditional clinic? Does it include telemedicine or is that not home based palliative care because you're not ... And we had Michael Fratkin on a while ago on our GeriPal podcast talking about telemedicine into people's homes.

Grant: Maybe I can start by talking a little bit about some of the models for home based palliative care, which I think gets a little bit at your question of what does it really look like and what are we talking about. And I'd say that there are probably four major models for how home based palliative care is delivered. One is through home-based primary care that often would be a primary care doctor or potentially a geriatrician or potentially a palliative care provider, but you're going into the home really to own all of the care that's going on with the patient. I think the VA is a good example of that. There are home based primary care program, they do a lot of palliative care and some of those programs will have access to specialty level palliative care providers. But that's one model home based primary care that does palliative care.

Alex: That would be a primary home based palliative care, like at the specialty versus primary. Like the VA, like when I think of the word HBPC I always think about Home Based Primary Care because it's grown up in the VA but they don't necessarily have palliative care expertise but they're really sometimes good at doing palliative care but they're not specialist.

Grant: That's right. There's certainly doing a lot of the work of palliative care but aren't specialty necessarily, especially level of palliative care.

Brook: I will add that, we have a really terrific, relatively large home based primary care program at UCSF called, Care at Home, which was initially the sister program of our more traditional home based palliative care consultative model, which Grant will talk about. But many of those clinicians are palliative care boarded. The physicians and then the nurse practitioners too, for the most part have gone through advanced certification in palliative care. So, that is, they may not be palliative care doctors, but many of them do have specialty training.

Grant: So just to say, a second model of home-based palliative care is home health plus. I think the Sutter AIM program might be the best example of this. Where I may not be a physician or a nurse practitioner, but a nurse and a social worker who might be going to the home to help support advanced care planning or goals of care conversations. The third would be a hospice based program. Where hospice is expanding their traditional services and providing palliative care. So they are figuring out their funding source, but it's then providing palliative care at home.

Eric: I feel like that's a big rapid growth area for hospices.

Grant: For sure.

Eric: But, this is different from traditional hospice.

Grant: That's right.

Alex: In patients homes. So sometimes we draw those Venn diagrams about palliative care and hospice. Is home hospice within the Venn diagram of home based palliative care or is that not? Sounds like you're suggesting that not.

Grant: I tend to think of them differently. I'm curious Brook, if you feel like that as well.

Brook: I'm not the best with Venn diagrams.

Alex: But you think of home based palliative care and home hospice as distinct.

Brook: So I think that they share a lot of the same features in terms of excellence in symptom management, excellence in communication, a team based approach. In order to be, let's say certified. So there's a certification for community based palliative care, through Jayco now. In order to be certified, one of the requirements is that you offer 24/7 access to care as a home based palliative care program. So, those are some of the similarities with hospice, but obviously, or maybe not obviously, I'll say, you don't need to have a lesson six months prognosis to be seen in home based palliative care. Many of our patients are still seeking curative or life-prolonging therapies and some of them are not, but some of them feel that at this point hospice is not the right fit or doesn't align with their goals of care.

Alex: Yeah. So you were saying that there are some hospices that are starting their own home based palliative care programs and those are staffed by clinical ... physicians, nurse practitioners, clinicians. Is it multidisciplinary team? I'd say there can be variability. This is just from what I learned when talking to some of the organizations in the area. I think a good example actually is UCSF partnership with hospice by the day and that's where Brook was serving as a physician, overseeing nurse practitioners who were employed by hospice by the day to go provide home based palliative care in San Francisco. Do I have that right Brook?

Brook: Yeah. So we have a whole team of physicians, nurse practitioners, social workers, chaplains, who are helping to take care of people in their home. And, I think one of the reasons that a hospice may decide to offer a home based palliative care program is, number one to expand access to people who don't otherwise have access to palliative care and also to potentially increase their referrals to hospice and hopefully get people into hospice earlier.

Alex: So first program is like a home based primary care program that has an extensive or may has a palliative care component in what they're doing. And the second is more like a bridge model, is it's known in many parts of the country where they don't have Sutter AIM for patients who are an extended home health program. And the third is these hospices creating their own home based palliative care programs. What's the fourth?

Grant: I'd say the fourth is a specialty palliative care team that is doing this work, not necessarily on their own, but as part of a large academic medical center or something like aspire health where they're their own entity and they're working with patients to provide specialty level palliative care.

Grant: I'd say that model is also what you see as home based palliative care program is. It's specialty level palliative care going into the home to deliver palliative care.

Alex: Brook, you want to say thing more about that fourth model?

Brook: Yeah, so that type of fourth model is, we essentially have two models at UCSF, the one that I mentioned before that's with our affiliated hospice agency. And then, our model that is primarily taking care of our fee for service patients, which includes all of our Medicare patients for now until we hopefully have better ways to pay for it, is our other model. And again, that includes a whole team but the services are, I would say more limited. We are not providing 24/7 access, overnight and on weekends we can do a limited amount of urgent visits but because of the way that we're financed, we don't have as full array of services as others might.

Eric: So what are the common ways people get financed? How do these programs get supported?

Grant: There are a couple of different mechanisms. I think one that people sometimes rely on is philanthropic support or grant based programs. Sometimes large academic medical centers will buy into the importance of palliative care and help fund that through getting revenue from other sources, other fee for service sources. Independent provider groups sometimes do direct contracting with payers. That's like aspire health, resolution care I believe also going to the payer and saying, "Let's work together to come up with a plan to pay for our service." And then I think there's some newer pilot demonstration projects. They're really coming out of CMS and CMI. So the Medicare care choices model or NCCN is helping to provide payment for hospices to do what we talked about in that third model hospice to expand their services to allow you to get fee for service benefits while you're getting hospice services.

Grant: Another program is the direct contracting model option where you can basically take on more risk. So it's like the idea of accountable care organizations where you might get some upfront payment or a value based payment towards the end. And that's another mechanism. And then I think one of the newer models is the primary care first models, which are just rolling out and they have a serious illness program within that where patients who have chronic complex needs, who do not have a primary care provider, can actually have their care taken over by palliative care specialists to provide wraparound care. And again, it's really a risk based model where there's a per member per month payment plus a visit fee to help reimburse. And then you do your best to try to provide really good care at the cost. So these are models that I know about.

Eric: And you mentioned JCAHO?

Brook: Mm-hmm (affirmative).

Brook: The Joint Commission.

Eric: The Joint Commission. They actually certify home-based palliative care programs.

Brook: They do. So, just like there's JCAHO for hospital palliative care programs. They now have a community based palliative care certification that's new within the last few years, I would say four or five years. And, it's available not to all of the different types of models that we've talked about, but it's available to home health and hospice agencies that are offering home based palliative care now.

Eric: Why would I want The Joint Commission certification?

Brook: I think because it's a really fun process to go through, probably [laughter].

Eric: Does not sound fun [laughter].

Brook: I think from a global perspective, it's important that we're trying to standardize the work that we do and make sure that there is some quality assurance to the care that we're providing. From a practical perspective, if these programs are going to be contracting with insurance companies. So, for example, the program that I mentioned with our local hospice agency, Hospice by the Bay, that program is called By the Bay Health. We're contracted with three payers who pay us a certain amount of money per month to take care of each of their patients. And, one of those payers, at least out of the three is basically requiring that they're only going to contract with home based palliative care programs that have the JCAHO certification.

Eric: [phone ringing] It's my phone [laughter]

Alex: Siri is listening. She's commenting. Siri, do you have a question for us? [laughter]

Grant: Siri is very excited about home based palliative care. [laughter]

Brook: She's yelling JCAHO, JCAHO. [laughter]

Eric: My phone doesn't ring until I start a podcast. [laughter]

Alex: I think the standardization ... this is really important that we are held to the same standards as other important clinical services. And Grant, you mentioned Aspire Health a couple of times. I wonder if you could say a little bit more about what that is and how it came into being.

Eric: Is there a connection here?

Grant: So Aspire Health is a home based palliative care company and the connection is my brother helped to start that and was a CEO of that company for awhile. So they were sending providers to homes to provide direct palliative care, to providing 24/7 telephone assistance.

Eric: And this is a for-profit company that did ... how did it do?

Grant: It did well. It did well.

Alex: Is there any quantification on well?

Grant: I don't have any numbers for you, but I would say that they grew quite quickly and serve many patients.

Alex: In a particular geographic region of the country?

Grant: They're actually all over the country. So I forget how many cities but it was somewhere out over 50 cities.

Alex: Are they the largest provider of home based palliative care in the nation?

Grant: I believe they are. I believe they are. I believe they are.

Alex: And it also shows because of their rapid growth. Would you say that'd be fair, that there is a tremendous market for this?

Grant: I think what made them very successful was their ability to create these contracts to figure out how to work with payers, to do a shared savings model and to figure out how it could be a win for everyone, including patients and families.

Brook: I was just going to make a comment about that because I think it's something that, when you think about scalability of these programs is really important, which is, that you got to be big enough. It's really challenging to be a small home based palliative care program of which many, many of the programs throughout the country are right now. Because hitting that sweet spot with staffing and how you staff is a challenge. The other thing I'll say is that, if you don't have enough contracts with payers, like Grant was talking about with Aspire, you need some diversity of the people that you're seeing. So as an example, if you only have one contract with one payer, who they're all 40 year olds with metastatic cancer, unfortunately as an example, those are very, very expensive people to take care of.

Brook: Whereas if you do have a contract with a Medicare advantage plan as an example, some of those people maybe in their 80s and they have dementia, but they're stable and doing well at home, like they're going to require a lot less resources and care. And so having a big enough group of people to take care of and a big enough group of staff that can divide and conquer, I think it's really key for the success of these programs.

Grant: I'll just highlight that in interviewing a few of the programs around the Bay area in Northern California, those themes were very strong. Finding the right patients for the fit of the program and what the program will be able to provide in terms of resources was a real challenge. In addition to figure out how to provide the financial resources to pay for the program.

Alex: Is there a best staffing model? Like, we think about hospice, this clearly defined roles. You have to have supervising physician, you have to have nurses, you have to have social workers, you have to have chaplains, you have to have some, I think volunteer program, et cetera. How about for home based palliative care?

Brook: I think the answer is that it doesn't, and it also does depend. I think in terms of holding up what we believe to be true in palliative care, having an interprofessional team model is important. That's also important for things like JCAHO certification. Not to mention that just one more time and at the same time, I think the amount of each of those disciplines and how you take care of people is really going to vary based on where you're practicing, people's access to other medical care or not where they live. How far the drive times are between places, as well as things like, the types of people that you're caring for. So, as an example, one of the payers that we contract with as a managed Medi-Cal plan.

Brook: And so we take care of the managed medical which, for people outside of California as a Medicaid plan. And those patients and families have very different needs than our patients that we're caring for that have a commercial plan, and a lot more social needs, a lot more concerns around sometimes drug abuse and that sort of thing. And so, bulking up the social work support for those patients is really important. So I think part of it is your patients and your payer mix as well.

Grant: I'll just add to what Brooke was saying, that just from looking at the research studies on home-based palliative care, looking at that Cochrane review that looked at all the RCTs and multiple controlled trials, a common theme of team composition at least was physician, nurse or nurse practitioner who is also often serving as a nurse case manager and social work. Those seem to be the three entities that were just present in almost all of those RCTs that had positive outcomes and then having access to pull in as needed, chaplaincy, bereavement services, et cetera. So just from, I think what the data is telling us is that you do need multiple and an interdisciplinary team to make it work.

Eric: And then what does the actual home visit look like, let's say in comparison to a normal palliative care clinic? Is there any difference?

Brook: Yeah. I think so. We're in people's homes, so that's the first difference.

Eric: Yeah, that's a difference.

Brook: That's a difference. I think that the visits tend to be longer, because there's more of, you go in, you got to find a place to sit down, you got to pet the dog. You often will get offered water, an orange or tea. Those sorts of things. You got to set up your computer so that you can chart. So those things do take some time.

Eric: And I can imagine one of the first things you're doing is also assessing for safety, when you're going into these new homes too.

Brook: Right. Like if the dog's going to bite you or not. [laughter]

Brook: Yeah. So I mean that is a very practical important consideration of doing home visits. And, if you want me to, we can go into some of those specifics too, but safety is certainly key. And then, some the visits will be just with one clinician, some will be with multiple clinicians, like a joint visit. Alex to your question about telehealth and is that part of this, we are using telehealth and really cool ways, including sending one clinician to the home and then having one clinician telehealth in, so that both clinicians are not having to drive 25, 30 minutes. And that's in San Francisco. So if you're looking outside of San Francisco, seven by seven people are driving much, much further.

Brook: So that saves some time and in cost there. And then I think we're able to do more stuff, so you can do a more thorough med review because all the medicines, the bags of medicines potentially are there for you to review. You're able to get a sense of what it's really like to get in and out and around someone's house and what durable medical equipment they have and is it working and do they have their oxygen on, connected to their concentrator or not? So you're getting a sense for those things. I think, the other really special thing about home visits that's different than clinics sometimes is that you are also getting a sense of what caregiving is like in a very different way.

Brook: Like who's around, what are they doing? As well as, interesting opportunities and really important opportunities to sometimes talk with the caregiver one-on-one in a way that you may not get the opportunity to in a clinic visit when it's, here you are and then you're leaving. But, one of the things I love to do most when I do a home visit is, if you have two clinicians, have one clinician stay with the patient and then say to the caregiver, "Hey, could I take a look upstairs." And go upstairs. And that's when like real talk happens. You're able to provide some additional caregiver support. You're able to really understand what's going on and they can ask some of the really hard questions that they may not feel comfortable talking about in front of their loved one.

Brook: I really like one of Brook's tricks is the, "Oh, would you mind walking me to my car?"

Brook: Yeah.

Eric: So what happens in that walk?

Eric: So last week we had David Reuben talking about population based health for geriatrics and for palliative care. And he described the pyramid where you have the sickest at the top and the healthiest on the bottom and how we should tailor our interventions to the needs of the different populations. When we think about palliative care clinics, home-based primary care -- where does it fall? Do you need both? If I'm an academic center, do I need both the clinic and home based palliative care service and a telemedicine service and an inpatients service. How should we think about this and where does it fall on these pyramids?

Brook: I think it's quiet because that's a really hard question to answer and I think it's probably going to depend a lot on who you ask. I think that it's great to see people at home and I think if that was the one thing that you could do and you think you could figure out a way to finance that, then do that, that's awesome. Because it's the most wrap around comprehensive palliative care service that we have and at the same time we should also be cautious with our resources and we don't all have 300 contracts with different payers and so-

Eric: Economies of scale because it's not just, let's say the clinic visits, if they're the same amount of time, you still have to drive to the person's home.

Brook: Right, and then you got a park.

Eric: You got a park, which is in San Francisco, it takes another hour.

Brook: Right.

Eric: So, scalability is a big issue, right? For home based palliative care.

Grant: I agree. I think scalability is really a crucial issue. And I might just add to what Brooke said that, to answer your initial question. If I'm a patient and family, in my mind the most ideal thing would be you interact with one team and that team has the flexibility to figure out what's the right touch at the right time. Are you able to come to clinic? That might be the most economical thing for the team, but at some point when do we start leveraging telehealth, telephone visits and who are the patients who really need a clinician to come into their home? So it's not a perfect answer, but I think the ideal situation is that health systems, which may take unique collaborations and breaking down some barriers that we haven't done before, like academic centers, collaborating with community partners, collaborating with hospices, collaborating with payers to help figure this out might be part of the solution.

Grant: But to have a team that's flexible enough to really, as you described, provide the right care at the right time for the right people is the golden egg we're all chasing after. So I'm not sure how to get there, but I do think that there is a vision and having these components is at least a good start to work on that.

Alex: I'm just thinking about the going into patients' homes and just how revelator that has been in my previous clinical experiences. I wonder, do you have any stories about that are appropriately anonymized for our podcast about, "Oh wow, that's what's going on at home when you walk into a patient's home."

Brook: It's going to take a second.

Grant: While we're thinking about that, I do think one thing that is, there is a magic to going into the house, and I talk a little about this in one of the reflection pieces that it's just so different being in someone else's space and that the way you interact and the way I think they're able to speak to you and receive it as so different. It's hard for me to figure out exactly what it is about that. But there is something about being in their space on their turf where they hold a little bit more of that power differential that is very reversed when they're coming into clinic, into your clinic, your space. So I just say that to add to what Brook has already said about, what makes the home base visit different than a clinic visit or maybe even different than a telehealth visit is the physical space.

Alex: Yeah.

Brook: Yeah. I'm not sure I have a perfectly specific example, but I think one of the biggest, "Oh wow," moments that I frequently have going into someone's home is that you can only get so much information from a phone call or a clinic visit with how someone is really functioning at home. Like, we have all these questions that we ask. Like, how do you spend your days and can you bathe yourself and that sort of thing. And at the same time, people are choosing to tell you on the phone what they choose to tell you.

Brook: And I think in general, when people go into their doctor's office, their team's office, they're choosing how they present themselves. And a lot of the times particularly if it's a patient who might be wanting more treatment for their cancer, they're opting to present themselves as well as possible when they walk into the cancer center to see their oncologist and their palliative care team. And, I think that's one of the most elucidating things is when you go into people's home and you realize like, "Oh, every time I see them they're in bed."

Grant: Yeah. I was just thinking about when you go in and I can think of some joint visits where the side table to the bed has a drink bottle, last night's dinner, the remote control, their computer, their meds, and you're like, "I think they may not leave their bed very much because everything is right here." And it's that where you may not have gotten that picture as clearly as you do when you see it when you're on the home.

Eric: My last question for you, Brook is, let's say I'm starting as a clinician in a home based palliative care program, looking back in your career doing this, are there two or three top lessons learned? Like, "I wish I knew this when I started." Or a couple of things that you just always pay attention for when you're going to people's homes.

Brook: Yeah, actually, one thing that we haven't touched on a lot yet and I think is a struggle. I see it in the teams that I work with and I know has been a struggle for me sometimes in the past, particularly when I was starting out was, we're going into the most impossible situations. Like you're taking care of the sickest people. You're seeing people right after they leave the hospital. They may really in some cases need more support with hospice, but they're not willing to have hospice care and you're trying to take care of them through the services that you're able to offer. And people's lives are messy and people's goals of care can be really messy also and I think that that can be really challenging as a home based palliative care clinician because we like things to be tidy and they're not, particularly when you're able to witness it in people's homes often.

Brook: So, I think that's one of the things, if I was to talk to someone who was just starting this work is like, "We can't fix everything. We can do what we can do and it's also not our story." One of the things that one of my colleagues, Bridget Sumser, who's been on the podcast before too talks about is like, "It's not our story, it's their story." And so it may not be how I think things should be, or their goals may not be exactly what I think would be best for them, or that are even realistic or attainable, but it's their story. It's not mine. And, I think that makes this work more sustainable over time to remember that, that we're going to do what we can to support you within our power and the limits of everything else that's going on with our services and in your own life.

Grant: As a mentee of Brooks and a new attending, those lessons that she has taught me have been extremely valuable and to have learned self-compassion from her husband. A real gift. So thank you Brook.

Eric: Well, are there other things you think our audience should know or should we do a little bit more of that song?

Alex: Is there anything else? So we've covered enough?

Brook: I just want to put a plug for, I think it's also very easy to feel alone sometimes doing this work because it's different. Like when I go work in the hospital and then I see all these people that I know and you have resources at your fingertips quickly. And so it's very different and it can be very isolating to do home based palliative care sometimes. And, because these programs are so new, there's lots of opportunities for everybody to get more education about how to do this work. And so just wanted to put a plug in for things like CAPC.

Eric: And CAPC has a wonderful, it's called palliative care in the home, a guide to program design that will have a link to on our GeriPal website.

Brook: Yeah. So that's a great resource and there's a PDF that you can download. They also have some other modules that are specific in terms of how to build these programs and then obviously all the great symptom management, communication modules that they have. And then, also just a plug for the California Healthcare Foundation who's been very, very supportive in this space and has also developed a number of resources, both for program developers and then practicing clinicians to help support you.

Alex: Yeah, it's great. It's important to have some community here because as you say, when I'm doing consults in the hospital and I'm with this team all day, we're together all the time. We have our support network right there, one of our support networks. Where as when you're going out to people's homes, often solo, it's a completely different setup.

Brook: Yeah. And it's totally possible to build that community, but it absolutely takes intention.

Eric: Well, Brooke and Grant, thank you very much for joining us today. How about we do a little bit more than that melody.

Alex: Thank you. Join in wherever you want.

Alex: [singing] We learned in Sunday school, who made the sun shine through. I know who made the moonshine too, back where I come from. Blue eyes on a Saturday night, tan legs in the broad daylight, TVs, they were black and white, back where I come from. Back where I come from, where I'll be when it's said and done. I'm proud as anyone. That's where I come from.

Eric: All right.

Grant: Take me back home.

Eric: And with that a very big thank you again for joining us.

Grant: Thank you for having us.

Brook: Yeah, this was fun. Thank you.

Eric: And to all our listeners, thank you for supporting GeriPal.

Alex: To Archstone Foundation, thank you for supporting GeriPal.

Eric: And we are going to actually try one new thing too, moving forward from here is we're going to be using our number 929-GeriPal. That's 929-GeriPal where you can actually submit questions for us or just comments about something we talked about in the past podcast - and we'll be talking about our future podcasts too. We'll be doing that through our Facebook and Twitter sites too, through that 929-GeriPal number.

Alex: And what podcasts do we have coming up that people might call in with questions about?

Eric: That's a great question, Alex...

Alex: Well, I'm pretty sure our next podcast is about ... What is a Medication Error According to Patients, with Mike Steinman and Francesca Anacosia...right?

Eric: Yeah.

Eric: So medications, all about medications, deep prescribing medication errors. So if you have questions for Mike Steinman and-

Alex: Francesca.

Eric: ... Francesca, 929-GeriPal. And a very big thank you to Damon Green, Damon Anderson Green, who actually emailed Alex and me with that suggestion to add this to our podcast.

Alex: Great idea. We love hearing from listeners. Thank you.

Eric: Goodbye everybody.

Alex: Bye, folks.



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