Since the start of his career as a primary care, internal medicine physician, Dr. Richard Feifer has sat at the intersection of geriatrics, population health and value-based payment models.
The Program of All-Inclusive Care for the Elderly (PACE) model has long been a passion of his.
This made him the perfect person to serve as the chief medical officer at InnovAge (Nasdaq: INNV). Last year, Feifer stepped into the role.
InnovAge is one of the largest PACE organizations in the country. The company has roughly 1,800 employees and serves seniors in Colorado, New Mexico, California, Pennsylvania and Virginia.
During a recent appearance on Home Health Care News’ Disrupt podcast, Feifer talked about his vision for home-based care and PACE collaborations, why other providers need to learn more about PACE and InnovAge’s future-facing goals.
The below is edited for length and clarity.
HHCN: Can you also give us background on InnovAge’s business model and footprint?
Feifer: Our business model at InnovAge is the same as all other PACE providers. We enroll patients — in the PACE world, we call them participants — who are living in the community prior to enrollment, but who would qualify for nursing home placement based upon their level of impairment and their care needs.
We enroll them, and then we receive capitated payments for Medicare and Medicaid. Capitation is defined as receiving a fixed monthly amount per participant. From that, we need to provide for all the participants medical, physical, emotional and social needs — everything that they need from that point forward. Much of that is then centered around the PACE center. A PACE center is a physical facility in which the program offers an adult day center, a medical clinic, dental and other services. Extending from that, we deliver in-home services and in-home care. That’s PACE, and that’s what we do.
When you stepped into the role, what were some of your short-term goals, and what are some of your long-term goals for InnovAge now?
When I started about a year ago, my immediate priorities were to develop and build a strong cohesive clinical leadership team.
I also viewed it as critically important that I visit each of our centers as soon as possible, meeting with the primary care providers and with the nursing teams. I needed to understand what was important to them, what made them the most successful and if they had barriers to that, what I could do to help them, because care is all delivered on the front line, in our centers and in our participants’ homes. I went to work on that, put a lot of miles in the travel bank, so to speak, and got to all of our centers. I learned a lot about the PACE model and about what it takes to be a top-notch PACE provider.
I also viewed it as a top priority, and immediate priority, to launch what we call a triad operating model. A triad operating model is one in which there’s shared leadership and shared accountability between or among operations, medicine and nursing. That means that each of our centers then is co-led by a center director for operations, a center medical director and the director of nursing services. That alignment and shared leadership — that’s a great driver of success. We have the triad operating model at the center level, and also at the regional and the national level.
Now, turning to longer-term things that I’m working on now with this team — care model innovation. We are integrating behavioral health in new ways to ensure it’s very much part of the care delivery process, where we’re undertaking advancements in pharmacy care to improve medication safety, reduce gaps in care and ensure that pharmacy is optimized for each one of our participants.
We’re focusing a whole lot on palliative care, end-of-life care and advanced care planning, that’s so important for this population. We are talking about a frail senior population, nursing home eligible, and in many cases, they are within a few years of the end of their lives. We want to make sure that everything that they experienced in that time is consistent with their goals of care.
I would also say that, as part of care model innovation, we’re focusing a lot on addressing acute care needs. For example, when a chronic condition has an exacerbation without needing to rely quite as much on the emergency room or the hospital. This is very important because when frail seniors go to an emergency room, or go to a hospital, they often don’t have a great experience. They are exposed to potential risks, and sometimes things go wrong. They can develop ulcers, they can get infections, they can develop worsening of their confusion if they have cognitive impairment or worsening of dementia. Keeping them out of the ER and out of the hospital is one of our main goals. And then there’s providing care for their acute needs in the community setting or in our setting by bringing resources to them. We’re doing a lot of work around care model innovation in that way as well.
InnovAge is one of the largest PACE organizations in the business, and one of the few that have gone public. How has having that scale been advantageous, especially considering that the PACE penetration rate isn’t super high?
Whether public or privately-owned, all PACE organizations operate under the same federal and state regulatory framework, which is actually quite rigorous. We are all delivering a model that’s been defined by statute. That’s the commonality among providers, as we think about InnovAge and others.
I would also say that providers in the PACE community are incredibly mission-driven. That goes for InnovAge providers, as well, our physicians, nurse practitioners, physician assistants nurses and all the other clinicians on the care team. They’re incredibly mission driven. Again, that makes us similar to other PACE organizations.
From our perspective, scale is important. It has allowed us to make some pretty significant investments, like building new centers in new states, so that we can expand access to PACE nationally. Also, transitioning of our electronic health record. That provides advantages around integrated care planning, integrated teamwork, and some other aspects of the PACE program and PACE requirements that are now part of our common platform. Those are investments that are hard for a small organization to make, but we’ve made them because we believe they’re going to help us be a better organization and provide better services and care.
Why is the PACE Model so successful when it comes to caring for seniors?
The PACE model is successful because it’s designed to meet frail seniors where they are — providing what really is a concierge-like care experience to help them stay independent, as long as possible. That is the entire mission of PACE.
Another reason for its success is that it reflects the very best principles of geriatric care, including an interprofessional health care team, and highly personalized, patient-centric care. This is what geriatricians learn about when they’re in training, and dream of when they’re in practice, and that’s what we get to do each day.
What do you expect the PACE market to look like in five years, and what part will InnovAge play in expanding the model?
Our mission is to expand PACE opportunities around the country. We look forward to PACE no longer being the best-kept secret in health care, which is something that I think is fair to say today. That means that we want patients and prospective enrollees to know about PACE as an option. We want family members and caregivers to know about PACE more than they do today. We want policymakers who are looking for ways to improve the health care system and the care experience for seniors to think of PACE as a key element of those solutions.
The role InnovAge will play — the role we’ll all play together — is through greater partnerships across the health care system. We need greater partnerships vertically. What I mean by that is, from the hospital system, to post-acute care facilities, to PACE and community-based providers.
We need greater partnerships and integration, as well as horizontally across providers of care, so that we can share best practices. Even within the PACE community, where we are operating in different states and different counties, we need to collaborate as much as we possibly can, finding better ways to care for this population. That’s what’s going to make PACE even stronger over the coming years.
How does InnovAge work with home-based care providers? What value do these collaboration bring to your company? What can home health and home care providers do to better involve themselves in PACE?
Because of the mission and the very design of PACE, home-based care is an integral part of the model. It helps us keep our participants, and keeps people living in the community as long as possible. That is one of the key objectives of PACE.
We enjoy working with home-based care providers so that we can learn about our participants’ environments, what’s important to them, and also where the risks are that we need to mitigate. We can work to keep them safe for as long as possible. We can design our care plan around our participants’ goals, which often involve independence. In some states, we operate an internal department of in-home services, so those home-based care providers are very much a part of our team. In other states and locations, we partner with local providers and we tailor that to the local conditions and what’s needed by our participants.
[Home-based care providers] should get to know their local PACE providers and develop deeper relationships. They should seek to learn how the PACE model is different from the traditional fee-for-service referral system. With that different level of understanding, they can find better ways of working together to achieve common goals.
What are some challenges that seniors face that you believe home-based care providers and PACE operators should be coming together to solve?
One of the big challenges that seniors – and PACE participants – face is when they require increasing levels of support, because their frailty is worsening, or their chronic conditions are worsening. That happens over time. Sometimes the decision becomes whether to shift the participant or the patient’s location, from being independent in the community to maybe an assisted living facility, or even a nursing home. That may not be consistent with the participants’ goals of care, because as I said earlier, independence is why so many people sign up for PACE.
That raises the question, maybe other solutions can exist to address the increasing care needs, other than moving into a residential facility? Maybe creatively staffing senior housing settings with caregivers and providers that are accessible and even on-site. That could involve a partnership between the PACE organization and home-based care providers with an aligned objective of avoiding institutional placement whenever possible. That’d be an area that would be wonderful to work on.
Three to five years from now, what do you want to be able to say you and InnovAge accomplished?
There are a couple of ways of looking at that. From an operational perspective, we are focused on recruiting the best talent and having industry-leading clinician retention. That’s going to drive even better clinical outcomes, and participant satisfaction, which are key measures of success. I want to look back and see that we achieved that.
We also want InnovAge to be a key reason why, three to five years from now, vastly more people in our country have access to PACE where they live, and vastly more frail seniors are able to live independently for longer, through the best geriatric care and the best support that our health system can provide. I believe that’s PACE.