Taking Healthcare by Storm: Industry Insights with Dr. Dave Thimons

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Dr. Dave Thimons, Founder and CEO of Personal Care Medical Associates (PCMA). 

Dr. Thimons discusses the importance of palliative medicine in improving the quality of life for nursing home residents and reducing hospitalizations. He highlights the benefits and misconceptions of palliative care, emphasizing the necessity of patient-centered care and the ROSE program's role in redefining end-of-life care.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

Publication number QI-071825-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

 Hello everyone, and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical director of Quality Insights, and we are gonna be talking about. One of my very favorite subjects. Today I am honored to welcome Dr. Dave Thimons, a physician whose career has been defined by a deep commitment to caring for the frail, elderly, older adults, and transforming healthcare delivery.

For the most vulnerable patients with over two decades of experience in geriatrics, hospice and palliative medicine. Dr. Thimons is not only board certified in these specialties, but he's also a certified medical director, A CMD, and is the founder and CEO of Personal Care Medical Associates, or PCMA.

He has built a practice that reaches patients across skilled nursing facilities, assisted living communities, hospitals, and homes. In addition to his leadership roles, including serving as deputy CMO for Aspire Health, he has contributed to groundbreaking research policy initiatives and national conversations on reducing hospitalization and improving care models.

I am so excited for this conversation. As I said, we're gonna be talking about the future of nursing home care for older adults in America. So Dave, thank you very much for joining us today. Jane, thank you for having me. I'm excited to be here as well. And congratulations for your work on this podcast. So it's an honor to be here and I love to talk about medical care in the nursing home world, and even more importantly, palliative medicine in the impact it can have.

And so I'm excited to be here also. Yeah, huge impact. So let's just jump in. Tell us how you came to do what you are doing now. Absolutely. And you know, I kind of do a handful of things, Jean, but I'm gonna focus on palliative medicine in the Rose program. And my personal story, it was 2012 and I was a physician and had founded personal care medical associates listed as a geriatric practice that provides care to patients in nursing homes and assisted living facilities.

And I was also a residency director at the time. My daughter was 12 years old and she was diagnosed with a bad bone cancer called Metastatic Ewing sarcoma. And so it was at that time in 2012, I quit as a residency director, continued to see patients in nursing homes, but really spent a year doing chemotherapy and radiation with her.

And she, you know, thanks to the goodness of God, is a miracle cure and she's okay. And she's actually working with us today, which is a great honor in my life. You know, she said to me at that time, dad, palliative medicine saved my life. They're the only people that listened to me, the only people that I felt like I could talk to, and that just resonated within me and really sent me on a palliative journey.

I thought to myself, if palliative medicine not done the traditional way. Done the way a very special man at Pittsburgh Children's Hospital did It could affect this 12-year-old girl in the way that it did. What about the thousands of patients we care for in nursing homes? And so Jean, that was really the, Inciting factor that sent me on a palliative journey, which I'd be happy to talk about the steps that ultimately led us to developing the ROSE program. And real quick, the last thing I'll say here is the ROSE program is the palliative medicine arm of Personal Care Medical Associates. We are a geriatrics skilled nursing provider at PCMA and we also have a consultative palliative medicine arm called the ROSE program.

Yeah, I think a lot of individuals, especially in nursing homes and and I, as I've spent a lot of my time in nursing homes, I. Individuals get very confused with palliative care and hospice. When you bring up palliative care residents and families will say, well, we are not, we, we are not interested in hospice right now.

They, they're not ready for hospice and they really don't understand palliative care and the impact that palliative care can have in quality of life. And even there's research to show that it improves length of life for certain diagnoses like congestive heart failure. As I said, it's palliative care is misunderstood.

So can you clarify its role and why it's so essential for improving quality of life for residents in nursing homes? Absolutely. I'm gonna clarify its role, but I'm, if you don't mind, let me step back and also talk about why we call it the ROSE program and why we don't call it PCMA Palliative Medicine.

And I think a lot of that will answer your question in a roundabout way, if that's okay. Absolutely. So. When I started my palliative journey, I did some work with CMS and, and worked, did some grant work and eventually became the Deputy Chief Medical Officer for Aspire Health, which was at the time the nation's largest home-based palliative medicine practice in the country.

And, you know, at that time it was a great privilege because I was afforded the opportunity to travel around the country and meet with most of the payers and a lot of big academic institutions. What I learned is there's a lot of really smart people out there writing textbooks and giving lectures, but the care that our patients receive in all corners of this country and nursing homes toward the end of life is subpar.

And it really led me to look at why does palliative medicine fail? CMS years ago came out with a statement that said 70% of patients in nursing homes need palliative medicine, yet only 2% receive it. And then I looked at what palliative medicine companies are out there and to date, you know, the outside of the Rose program, there are no palliative medicine companies in the country.

I. That make a profit  that aren't run as a loss leader for a hospice. And so what I learned is palliative medicine traditionally fails for two reasons. One is the word palliative is its own worst enemy Jean. And I think you hit it on the head. If I walk into a patient and say, hi, I'm Dave Thimons, I'm your palliative physician, they're likely to say, but I'm still getting chemotherapy.

I still wanna see my cardiologist. I'm not giving up and dying. I don't want palliative And. It's that misunderstanding and misinterpretation of the word that I think prevents patients from getting the care they need. And so for that reason, we call it the Rose Program. Now I say, hi, I am Dr. Thimons. I am your physician with the ROSE program.

I'm here to talk to you about your illness, let you know what the next few years are going to look like, allow you to plan for how you wanna handle the changes that will happen in the next few years. I wanna work with your attending physicians who are doing a wonderful job to make sure that you don't suffer while you're going through the care.

That they are delivering. And what we can do by doing this is changing palliative medicine from crisis care, because that's what it is in the United States right now. But what it should be if done right, it should be preventing a crisis from ever happening. And so it's really. That education to say what is palliative medicine and what's the difference between that and hospice? You know, and you know all this, but I'll go through it anyhow. Jean, for a patient to be eligible for hospice, they have to, the physician has to sign a certification that says if the disease runs, its expected course, life expectancy is six months or less.

And the patient and family's goals and values have to be in alignment for the most part with conservative care. So they have to be in their last six months of life and they have to not want aggressive therapy. What do you have? How do you become eligible for palliative medicine? You have to have.

Advanced illness, comorbidities and symptom burden. That's it. There isn't tight eligibility criteria like there is for hospice. So if you look at a big, large piece of pizza, hospice is one slice of that pizza and palliative medicine encompasses the entire pizza, and that's why CMS is pretty stringent on saying 70% of patients in nursing homes need palliative medicine.

The challenge has been how do we get it to be delivered right in the nursing home setting? The last thing I'll say is there is one more challenge, and I don't know about you. I think you're a lot younger than me, but when I was in medical school, I had zero classes on hospice and palliative medicine. And I think oftentimes a physician, when we wait for physicians to write consults for palliative medicine, we end up waiting until the patient is suffering. The family's crying, they're threatening litigation. A patient's been to the hospital four times and the consults come too late. Not only do we have to reeducate.

Patients and families in nursing homes about the benefits of palliative medicine. I think we also have to reeducate our own community to say, here is why palliative medicine needs to be brought in years before the end of someone's life to deliver better care. Help them not suffer through the last one to two years of life.

Allow them to enjoy their patients and families, not let them have fear, suffering, and despair. Also prevent unnecessary hospitalizations, limit unnecessary medicines, and it's really just about doing the right thing. And a lot of physicians will say, look, I understand what you're saying Dave, but I can do that.

And my response is, I know you can do that. And you, you, you're probably a lot smarter than me, but the facts are. Too many physicians are too busy dealing with all of the medical problems in these complex patients. And the palliative medicine done the right way takes time and they don't have time to do it.

And we have a lot of data that shows the benefits of working together. And so I think it's one, getting over the fear of the word palliative, and it's too really reeducating the entire medical community. Around. Let's not be afraid of this. Let's get it involved early. Let's get it. Most people engaged in an active palliative service because the outcomes speak for themselves.

Uh, they absolutely do. And I, I will say what I think is really insightful is that you call your program by a different name than palliative because I think that palliative care and hospice are just linked and it's, it is what it is, but. In kind of in separating your program, which  is palliative care, but renaming it, the Rose program, I think it, it really does, can then have the impact.

That it needs to have. And I think that you also really explain that well in that crisis care we are, we're like, I feel like we're addicted to crisis care in this country, and we really need to move away from that if we want to fix the broken system. And palliative care can certainly play a role in doing that.

I agree. And, and I'll just kind of say, we call it the Rose program because that's my daughter's middle name in honor of her. So. Just wanted to throw that out there. And one, one last, you know, really insightful piece of advice I received years ago from the original Chief Medical Officer at Aspire Health, a guy named Andrew Lasher, who's one of my mentors.

And every talk he ever gave, he said, you know, if palliative medicine were a pill, everyone in the United States with advanced illness would be on it. Yeah. And he said that over and over and over and it just really resonated within me. And, and, and I think he is a incredibly bright guy and a, and a real palliative advocate.

And I think that statement says a lot if we just pause and think about it. Yeah, I agree. So one of the huge big parts of palliative care is advanced care planning, and I'm sure it's a big part of the ROSE program. So can you talk a little bit about advanced care planning and the impact it has on nursing home residents?

And what are the biggest barriers to having these conversations effectively? 'cause nobody wants to talk about what their wishes are at the end of life, right? So it's really hard to have these conversations in ways that people remain open and receptive. Yes, you're exactly right. But let me go back and talk about this on a lot of fronts.

You know, I think that maybe a decade or so ago, there was a big push to get in the state of Pennsylvania polsts and other states, it's molst or whatever we wanna call it. There was a big push to get these forms filled out on all patients coming into nursing homes. And I think the community has done a pretty good job at getting these forms filled out.

UCSF did a study years ago that said, okay, we're now filling out the forms, but let's look at the quality of how we're filling out the forms. And there was no improvement in the quality. And so what we do is we, you know, we talk to our providers a lot about, I. You're not a short order cook. You don't sit there with the polst or a molst, or whatever we call it, and ask personal people questions and check the boxes.

The real barrier, I think, is in educating the providers about how to have a meaningful advanced care planning conversation. I find that most patients and families, although. Most patients and families are very open to the conversation if it's done in a way that is not threatening and if it's done in a way that they're afforded the format to ask questions and be a part of the conversation.

And so we do a lot of education around how to do this right. We don't do this to hurry up and check the boxes and answer the questions. We do this in a way to understand a patient's story. Let them tell you what their story is and how they want their story to finish, and then we recite it back to 'em and that's how we end up filling out the form after the question.

We're not allowed to call it difficult conversation at the Rose program. We call it a wonderful, beautiful opportunity to. Really get to know a patient and a family and, and what has meaning to them. These people are sharing intimate details of their life and their fears, and we should respect them in a way.

That they deserve. And so I think, you know, I think the most important thing that I talk about a lot is let's just not fill out the form. Let's focus on the quality of the form. Let's focus in healthcare about learning how to be silent and allowing patients and families to give us the answers. You know, if we oftentimes just be quiet, people will give us all the answers.

We don't have to be so smart to ask all the right questions. I love that we do need to learn how to be more silent, I think, in these positions. Most definitely. So you spent a lot of time in nursing homes and I, I just, I know PCMA is, is one of those organizations and is with the ROSE program that nursing homes want you in their facilities because you improve care, you understand how to improve care in the facilities so.

From your perspective, what does truly excellent care look like in a nursing home setting? Because I think a lot of people don't understand that.  What are the key components you think that are required to achieve that? Yeah, I think that's a great question. And I think it's multifaceted and you know, I'll tailor my approach to.

What great medical care looks like. But I also wanna just preface it by saying, great medical care is impossible without teamwork. With the facilities administration, with their nursing staff, with the rehab staff, with the restorative teams. And so I think, what does great care look like? The first and most important thing is you have to have.

A team that is all dedicated and devoted to doing the right thing by patients. And that team has to have open dialogue, communication, and brainstorming to come up with better processes. The medical component of that team. What do I think is really important? I think the old model, and you don't see a lot of this anymore Jean, but the old model of a doc rounding in the hospital in the morning and then the office in the afternoon and then swinging by the nursing home at night to see their patients on the way home for dinner.

And I was guilty of that early in my career. But that model just doesn't work. These patients in nursing homes now are sick. We have patients on a lot of IVs. They have a lot of complex medical problems. So I think what does great care look like? Number one, it requires on, on top of the communication and on top of a great administration and nursing staff, it requires a medical team who's devoted to care for the nursing home patients just like you are.

It requires a team that understands. The rules and regs in nursing homes. It requires a team that it is in the facility several days a week, if not every day. Knowing the patients and understanding what is wrong with them, understanding what their goals and values are, I think it requires a palliative team, like the Rose program to help communication and to help understand patient's goals and values.

And I think maybe. One of the biggest problems that I see in the nursing home world is polypharmacy. I think it also really requires an educated clinician to look at the medications that patients are on, to really look to minimize, if someone is on two medicines, there's a 10% chance of a drug-to-drug interaction.

If someone's on five, there's a 50% chance. If someone's on over eight, there's a 90% chance. Not long ago, I read a study that the average nursing home patient is on 18 medications. We know that 21% of all rehospitalizations in a nursing home come as a direct result of polypharmacy. So I think really aggressively minimizing medications is one key component that I don't think was really on our list to talk about today, Jean, but is really important to talk about.

So that leads into my next question that, that I think is so very important, and I'm sure it's a huge component of the Rose program, big component of palliative care in general, which is. Patient centered care, person centered care, resident centered care. It's just the, this, the foundation  and obviously polypharmacy is a huge part of that because, you know, you never know how medications are gonna affect a person.

And you know, really looking at the person. In general  I will just say as a medical director, as a collaborative physician talking to nurse practitioners, I don't know how many times I've had to go over a case of a resident who has dementia in a nursing home and they  the staff of the facility are calling because the chief complaint is, the resident has behaviors, and I, I will say it's very limited. I think that anyone asks, well, what are the behaviors that are so problematic, right? Like the behavior could just be the resident just keeps asking to go home and like that is deemed a problematic behavior.

 You know, I think about. Patient-centered care. It's critical. It's so critical in nursing homes. So, you know, in, in your experience and in in, you're talking to nurse practitioners and other providers, what are some practical ways, do you think facilities and providers can ensure that care is tailored to each individual resident and it's very patient centered?

Yeah, I think that's really, really important. I think it's important for, again, clinicians to be dedicated to facilities to really know their patients. I think it's important for medical directors or clinicians to be part of care conferences and team meetings, where collectively we can say, you know, we're not gonna talk about a nursing home policy today, but we're gonna talk about Mrs.

Smith. You know, and we know Mrs. Smith. When she's by the elevator and sees people leaving, starts to get that behavior that you just talked about Jean, of wanting to go home. So how can we know her so well that we know what triggers that behavior and how can we then implement plans to take away that inciting factor?

And I think the only way to do that is to be present, but not just be present, to be part of a team that is built around. Let's get to know this patient. Let's talk about, I think, number one, what are this patient's diagnoses, illnesses, and what are their symptoms? Number two, what are these patient's goals and values?

What does success in medical care look like to them? And then number three, how can we hopefully non-pharmacologically, make these patients feel better? Because, you know, at the end of the day. What is palliative medicine? You can look it up in the dictionary and you can find multiple sentence answers, but you know what palliative medicine is.

It's looking at patients with advanced illness and suffering and saying, how do we make them feel better? How do we make them feel better physically, mentally, emotionally, and spiritually? That's it. And the way to do that is to take the time and to really get to know your patients and to work with an interdisciplinary team to tackle these problems in non-pharmacologic ways is is the goal.

Yeah, looking at the whole person. So essential. So I just wanna touch on medical directors. I think it's a little bit of a hot topic now. You know, you and I are both certified medical director Cmds, and I think we both think that's very important. And you touched on, you know, kind of the, the old times, and I'll say my father is a.

Semi-retired internist who went to many nursing homes, had an office practice and also went to the hospital. So he was one of those doctors that went, you know, to multiple places and was primarily hitting the nursing homes, seeing patients in the nursing homes on the weekends. medical directors are crucial in the nursing homes and I think it's becoming more crucial and, and in California now there's a requirement by law that all nursing home medical directors are gonna need to be cmds certified medical directors, I think by 2026.

And the data shows that. Quality of care improves in these facilities that do have a certified medical director. They have lower hospitalization rates, they have improved quality measures. So how do you see the current state of medical directors in nursing homes and what do you think needs to change?

I don't know about you, but I just see massive variability. I think there are some amazing medical directors. You know, you're doing a great job. You know, Dave nace is a mentor at UPMC who just, um, does a lot of education and preaches the importance of being an active and good medical director. So I think there are some wonderful people there and I think there are a lot of old time docs who.

Probably are not engaged in what we view as a medical director as well. To no fault of anyone, I just think there's a lot of variability and I think in healthcare, a lot of times the system is afraid to hold physicians accountable, and I do think we as physicians do need to be held accountable. And I think the only way we're going to see real change.

It's probably to mandate that everyone's a CMD. I guess I have some concerns there from time to say, are there enough cmds to be medical directors everywhere? I hope so. Or I hope it pushes people to become CMDs. You know, maybe we say look. Every medical director doesn't have to be a CMD, but they have to be on a track to be, to become a CMD within a year, just so we don't fall short.

And I  I don't know if there's, if there's enough out there to staff all the nursing homes in the country, but  I do think the role of a medical director has to change from just showing up and referring patients to getting actively involved in things like. The admission process, the overall medical care, are all the physicians doing their job to really looking at polypharmacy and working with the pharmacy to minimize unnecessary medications.

To looking at, are we staffed, right? Do we have enough equipment or do we delivering the right therapies? And medical directors in an ideal world should be involved in a lot of this, but I think a lot of us haven't been trained to do that. And in the absence of going through a CMD course, I think there's a lot of really good people as physicians who just aren't trained to do their job the way that it needs to be done right now.

I, I would agree. And I don't think there's enough cmds. But I, and I think it's interesting. I think states are moving towards, I think now Pennsylvania has the requirement that if you're a medical director of a long-term care facility, you need to have four hours every year of CME. That's around long-term care medicine, but.

Yeah, we have a long way to go. Looking ahead, where do you see PCMA and the ROSE program in the next five to 10 years? Is there any expansions or innovations that you're excited about? Well, I have massive dreams of the ROSE program. Look, I love PCMA. But the truth is, there are other groups like PCMA in different parts of the country that do a wonderful job.

PCMA today takes care of patients in about 90 facilities within a two hour radius of Pittsburgh, Pennsylvania. And what our goal at PCMA is to always challenge ourselves, think outside the box, refine processes, and continue to grow density within our market and be the provider of choice in our market, and to raise the geriatric, you know, level of care in the western Pennsylvania region.

The Rose program to date sees patients in Pennsylvania, Ohio, a little bit in West Virginia and across the state of Florida, and there aren't other companies out there doing what the Rose program does. I just feel so passionately that every patient in a nursing home, most patients in assisted living facilities, all warrant screening for palliative medicine.

There's no negative to it, and they all deserve it. And so my real passion, I think, is to redefine what that word palliative medicine means across the United States and to make. Whether it's the ROSE program or whether it's another company that develops like the Rose program, make the Rose program and the right type of palliative medicine available to every patient.

Who resides in a nursing home or assisted living facility across the United States, and I think there is such a massive opportunity and one might say why, or do you mind Jean, if I talk about cost for a minute?  No, go ahead. Because I think everybody has cost in the back of their mind. Yes, that's always a barrier.

But you know, a lot of people, and I might give some wrong numbers here, so I don't want anyone to get mad at me. But let me give some guesstimates. A lot of people, again, we've already established that people correlate palliative medicine with hospice, and oftentimes a hospice cost can be in the four to $5,000 range a month, sometimes more.

The cost to palliative medicine, like let's use the ROSE program for an example. If any nursing home out there wants the Rose program, there is no cost. It will cost you nothing. You don't have to sign a contract there. We don't take work away from many physicians. There's no reason not to use it.

All we ask is that you follow our model because we know our model works right? The only cost associated with palliative medicine is a fee for service bill, and the average collection on a fee for service bill in a nursing home patient is about 60 to $62 a visit. So what we're looking at is around. 60 to $62 a visit for palliative medicine.

Yet we have data on the backend that shows a 40% reduction in return to hospital. I don't know what the average DRG cost for a hospitalization is out there, but I think it's around 14 or $15,000. So we're gonna pay $62 a visit to reduce hospitalizations by 40%. To decrease the number of costly medications patients are on by four pills per patient to improve patient and family satisfaction.

To allow a facility to say, Hey, we have palliative medicine, we can take sicker patients in nursing homes. We can increase your case mix index to improve your reimbursement. To decrease litigation. We find that palliative medicine done the right way, decreases litigation in nursing homes because why do people sue?

At least in my experience, they sue because they weren't communicated with enough or appropriately. They sue because they feel like someone did something that wasn't right. That they didn't know about. Well, palliative medicine does the right way, is all about effective communication, and so the cost is.

Extraordinarily phenomenal for the return, and that is why I am just so passionate that all nursing homes out there should be offering a meaningful palliative medicine service like the Rose program. I think it's a really important to talk about those numbers because, you know, what people don't understand is  the majority of individuals spend.

The end of their life, the last few months of their life, the last month in the hospital, and it doesn't buy anything. It doesn't get them anything except perhaps. Increased suffering. And so, you know, palliative care done well then can improve quality of life at the end of life.  And so they're not, these individuals aren't spending it in the hospital and that's what the research is demonstrated.

 And it is, does turn out to be.  Less costly if you're not in the hospital, but, you know, we sh we don't need to be spending money on making people suffer. So I think Jean, we're in such a unique and cool profession because I can't think of any other industry where I. Adding a service and doing the right thing and providing better care actually costs less.

Yes. Like taking medications away. Yes. Like, we're really blessed. So how do we get my question and challenge back to you as the host here, is how do we get this message out better and how do we get people to understand it? Because I love to talk about it and  I, I just want it available to everyone who needs it so badly.

Yeah  I agree. So I, the last question, and I think I know the answer  if you could change one aspect, one major aspect of nursing home care, what would it be? And do you think policymakers can make it happen? I don't know. I have my doubts, but maybe you're more optimistic than I am. Well, I think it's a big question because.

I think a lot of challenges in the nursing home industry come from payment policy payment reform.  I, I really think that payment reform needs to happen. I think that policymakers need to talk, really talk and put, just like physicians in this day and age are being shifted to pay for value and pay per quality.

I think that nursing homes should be challenged to do the same, and they should be given the opportunity to bring in more dollars, not for their pocketbooks, but to reinvest those dollars in meaningful programs, increase staff. Better ways to deliver better care for these patients. And so I think that. If we can, again, not think about spending money today, it's gonna cost more, but how do we get people to understand that if you spend a little more money today, we can probably save 10 x that money in two years?

By taking that money and building collaborative teams of certified medical directors and instituting programs like palliative medicine, getting us all to work together. To create that patient-centered approach. And I think that if policymakers can see the unnecessary cost and to say we have to get ahead of it by increasing spending to decrease that cost at the end of the road, um, I think that would be beyond important.

Yeah. And provide better care as they, as cost comes down. Most definitely. I agree. Dr. Dave Thimons, thank you so much for joining us. If people want to find out more about PCMA, can they go to the website? Would that that be the best place? Yes. It's just uh, www.pcmanetwork.com. And we have information on PCMA and the ROSE program is right there.

And, um, again, we're really passionate about what we do and we would love to help anyone build a meaningful palliative medicine program in their facility. Yeah, I encourage long-term care facilities looking to integrate palliative care into their facilities. Please go to the website, find out more information, and reach out Dave.

Thanks so much for joining us. It was a wonderful conversation. It was great to talk to you and keep up the good work. Thank you. Take care.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

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