Patient-Centered Palliative Care: Insights from by the Bay Health

Dr. William O’Connor: With us today on the show, we have Dr. Kai Romero, who is Chief Medical Officer at By The Bay Health. Welcome to the show, Dr. Romero.

Dr. Kai Romero: Thank you so much for having me.

Dr. William O’Connor: You’ve got an impressive background in medicine. I can see some experience at Harvard and UCSF Medical school. Very impressive. Tell us a little bit about that and kind of how you got your start in medicine; a little bit about the origin story.

Dr. Kai Romero: Yeah, so my origin story, like many physicians, is rooted one generation before me. A little bit more unusual is that my father moved here to the United States from Mexico as a 13-year-old migrant farm worker and in the course of doing that work, recognized that there was just a big gap between what he saw the people around him experiencing in healthcare and what he imagined it could be. He was also a person who was and is kind of a business guy, and so he thought well, I’m making this amount of money doing migrant farm work, I bet I could be doing better as a doctor. And so he threw a series of lucky accidents including being drafted as a foreign national for Vietnam. Went and joined the army, learned English, came back and on the GI bill, went to college. Actually went to community college having missed sixth through 12th grades and then onto UC Irvine and UCSF. And became a family practice doctor running a migrant farm worker clinic for the last 30 years. 

Dr. William O’Connor: Wow, that’s amazing.

Dr. Kai Romero: Yeah, pretty wild story and so as a kid I grew up with this sense of how do you meld kind of the stability of having a professional career but with mission-driven work and medicine was always really top of mind for how to do that, I originally pursued emergency medicine, thinking that was really where my passion lied. And a lot of the reason for that had to do with the fact that I loved the open-door policy of the emergency room. There was no filtering out of patients on the front end, it was really come as you are, and we will see you, and we will care for you. And that having been said, one of the things I noticed relatively quickly in my training was how complicated it becomes to be a seriously ill person in our healthcare system. And how hard it is for emergency rooms to meet that need. And so that kind of piqued my interest in what things might look like for patients who are seriously ill but don’t end up going to the emergency room. I ultimately ended up deciding to do a palliative care and hospice fellowship and found that there’s actually quite a bit of overlap. You wouldn’t imagine it, but there’s quite a bit of overlap between the two fields primarily in the sense hospice patients have the same emergencies as ER patients do. They just happen at home without an IV and without advanced equipment to manage them. And as a result, you have to do a lot of similar problem-solving and thoughtful diagnosis and treatment, but you’re doing it all within a far more resource-limited setting. And that’s kind of what drew me to hospice and palliative medicine and into my current role.

Dr. William O’Connor: That’s an amazing story about your father. That is a really impressive growth to come here with that job and advance all the way up and through, so that sounds like it was a fairly big inspiration for your career.

Dr. Kai Romero: Yeah, I think it’s interesting because there’s almost this myth of what the American dream looks like, right? And I think by all accounts, having leapt from abject poverty, dirt floor in Mexico to being upper middle class in California is that lea. But when I think of what created that for him, it had a lot more to do with being obstinate in the face of naysayers. Kind of just like not trusting anyone who thought that this was too big a leap. It also had to do with these structural things like the US Army who didn’t see him as a migrant farm worker, they saw him as cadet number 70 million whatever. Did an IQ test, and we’re like hey, you’re too smart to be picking lettuce. He was like, okay, I don’t know what to do with that information, but he kind of needed someone to not look at him as a poor immigrant, but instead as a number and say this number does not fit with that job class. In order to start thinking outside of what he’d been doing. And I think for me, the other piece is what does it look like to be dedicated to a community for 30, 40 years as he has been?  And this is something that comes up, I think, with some regularity in hospice and palliative medicine, that sometimes physicians have this sense that they’re like giving this gift of their presence to patients and families. And I think my dad is just much more pragmatic, he’s like, people are paying me for a service. This is a service I can provide sitting in a chair, not doing backbreaking labor, and not dying young from just the ravages of poverty. I think he just understands what’s actually being traded, instead of coming in with this kind of complex about how a patient is benefiting from this exchange. I think he fully understands how he is benefiting from the extremes, kind of financially and lifestyle and otherwise. And I think that is how you remain committed to mission-driven work over the long haul. The recognition that it’s an exchange, not a one-way street.

Dr. William O’Connor: Dr. Romero, tell me a little bit about what that transition was like from the emergency department. I know you said there are some similarities, but the emergency department could be as you said, you never really know what’s going to walk in the door. It can be an extremely high-paced, high-energy environment, tell me a little bit about what that transition was like when you switched from going into the emergency department into palliative care.

Dr. Kai Romero: Yeah, I certainly think that a decent chunk of the people that pursue emergency medicine are adrenaline junkies. And they’re like that in the emergency department and they’re like that outside of the emergency department when they’re riding their skateboards to work or doing whatever high-risk activities they are. And I would not describe hospice medicine as adrenaline-driven, and when I first started as a hospice and palliative medicine fellow, the number one thing I had to learn was how to sit still in a meeting, which seems ridiculous, but I had zero experience doing that. It was like when you round in the emergency department, everyone’s standing, you’re moving from room to room, you’re speaking about people quickly, and you’re moving on. And the thought of sitting still for two and a half hours and hearing about people’s existential grief, I was like, I don’t know, I’m going to flip this table over. I don’t know what I’m going to do.  So I think that step one for me was the recognition that there was a depth of engagement that had to happen with my patients that was really different from what I had been trained in. Then I think just the care that we provide in the home necessarily has to take into consideration both these acute peaks and intensity as well as the periods of quiescence in between. And that is really hard to kind of keep paying attention to over time. I mean everyone’s focused on those, right? Everyone can kind of rally the troops for a CHF exacerbation or something else. But when all of that goes away, the patient is still there, their life is still there, and maintaining a kind of intensity of care through that can be a huge challenge because it’s not calling your attention in the same way.

Dr. William O’Connor: Tell me a little bit about By The Bay Health specifically.

Dr. Kai Romero: So By The Bay Health is an organization that has existed since the 1970s. It was founded by our founder, Mary Taverner, the second-oldest continuously running hospice in the country. And over the last several years has branched out from exclusively providing hospice care to providing palliative care and home health as well. We also have a dedicated pediatric team, which is pretty unusual in the hospice and palliative space. And we’re a nonprofit and try really hard to partner with patients in their homes to give them care that meets their needs wherever they may happen to be in kind of the larger trajectory of their illness. And it’s clear when a patient comes into hospice, like what they’re looking for and what their prognosis is, it is much less clear when a patient becomes a home health patient because they might start out in acute recovery from an event. And the fact that we have a home health branch that’s kind of under this broader umbrella of hospice and palliative care means that our home health providers have more of an eye to, is this continuing to work? You know, is this rehab continuing to help this person, or have we kind of switched over into another mode? And I think that really benefits our patients as well because we’re kind of trying to identify early enough once we’ve started engaging in a futile exercise. Which unfortunately, as you well know, a lot of medicine kind of becomes at some juncture, and it’s not a question of if it does, but when it does, and whether there are enough people around you that are skilled enough and willing enough to identify when someone’s decline has become evident.

Dr. William O’Connor: You know, that’s a pretty broad set of responsibilities. Hospice, palliative care, home health, you have a pediatric arm, and as you said before too, when you have a CHF exacerbation at the bedside, it’s easy to rally the troops. How do you keep these people connected? And the other thing you said before really resonated. It’s complicated to be a patient nowadays. What are you doing to connect to patients in all the different areas that By The Bay Health is covering?

Dr. Kai Romero: So one of the things that we have incorporated, especially since the start of the pandemic, was the recognition that we needed more kind of points of contact with our team. Then we could provide physically at all times. So this is probably true in lots of parts of the country, but here in the Bay Area, in addition to COVID, we’ve also had these large fire seasons where parts of highways are shut down and it’s actually just physically challenging to get to patients. Or the air quality is so bad that people aren’t supposed to be going outside, et cetera. So what we’ve found is the need for flexibility around communicating with our patients quickly and  reliably in crisis. So whereas in a normal time when we have plenty of staffing, there isn’t a disaster, there isn’t a pandemic, we can have a predictable arrival time for our nurses. That all goes up in the air when any one piece goes out the window.  And so one of the tools that we’ve used a lot more of is telemedicine in order to do real-time communications with patients and families in addition to secure texting with patients and families to make sure that they can know that they have a responsive care team regardless of what might be happening in the milieu. One hallmark of hospice and palliative medicine is the use of interdisciplinary teams to care for patients. So it’s not just a nurse or a doctor, it’s also a social worker, a chaplain. And what the use of telemedicine has done is basically made it much easier to create a multipart interdisciplinary meeting with families so that it’s not reliant on any one person’s particular schedule, ability to drive X, Y, and Z location. And it’s not infrequent that we’ll have a nurse physically go to the house. The physician on video and the social worker on video so that everyone can kind of be in the same conversation about the care plan.

Dr. William O’Connor: That seems like a pretty significant difference to me from just a few years ago, really connecting your interdisciplinary teams, via different communications technology. How  has the response been from the patients?

Dr. Kai Romero: What’s interesting, the team for us that does the most interdisciplinary team via video conference is our pediatrics, and part of the reason why is they actually have many more members of their interdisciplinary team. So in addition to the people that I described, they also have music therapy, they have child life specialists, I mean, their interdisciplinary team meeting can be many people. And as you can imagine, there are families for whom technology’s always going to be kind of daunting and overwhelming. But there are families who absolutely benefit from two things: one, the speed with which that visit can be made, right? If you’re not waiting two weeks to get everybody on the same page. But also the use of the in-person staff member as like the conduit to the technology can be really helpful as well. And I do think that patients and families appreciate the whole patient care that they’re getting. And the move away from the medicalization of their end-of-life care and towards this kind of broader understanding of them as a whole person.

Dr. William O’Connor: It sounds like you’ve gotten a lot of good feedback from patients in terms of how these interactions go now and leveraging communication technology, specifically telehealth, to augment that visit. And it sounds like the speed with which you’re able to get to patients is faster as well. Have you noticed any outcomes in terms of your staff? Are they more satisfied with the technology? Are they able to see more patients? Is it more convenient for them? Can you talk about that a little bit?

Dr. Kai Romero:  It’s interesting. I think there’s a broad range of how people respond to it. We find that we have much more adoption on the palliative care side than we do on the hospice side. I think a lot of that has to do with the fact that a lot of the role of a hospice nurse can be very physical. Like wound care or literally opening a bottle of pills to count the medications. And so telehealth is not as easily adaptable to that. Some of it is also generational. I think that our millennial nurses are quick to secure text, they’re quick to do telemedicine, and some of our nurses that didn’t grow up with this technology are less so. But I do think that our staff really does talk about benefiting from seeing the framing of their work by different people in real time and I do too. When I’m in a meeting and I hear a social worker describe what it is that they’re doing around existential grief with a patient, it shapes how I talk about symptom management or goals of care. And I think that kind of real time learning from your peers is greatly enhanced by just having more exposure to them.  I also think in this world where, again, this might be more Bay Area specific, but we’re still more siloed and more remote than we were prior to the pandemic. It’s an opportunity for connectedness with your colleagues. Overwhelmingly, when we ask our staff why they work at By the Bay Health, they talk about their colleagues because it’s a mission-driven organization. It’s a nonprofit and that’s a big part of why they choose to be here. So the more opportunities they have for that type of exchange and interaction and really learning from one another, the happier they are and the more satisfied they are with their work.

Dr. William O’Connor: Yeah, that makes sense. You know, especially when you do have a remote workforce and people are moving around seeing patients and having the opportunity to connect more.

Dr. Kai Romero: These social workers and chaplains are so skilled, and they’re so skilled in a way that is so different from mine and so different from many of the nurses that I always think of it as this incredible gift to be able to hear someone think and communicate and talk in the way that they do. And I walk away with freezes of what they’ve said and think oh, I’m going to use that with a patient in the future because that’s their specialty really. And you learn as much as you can within the context of your field, but I think it’s definitely an opportunity for some cross-pollination and some ongoing training that’s super intentional and directed, but it’s just kind of by osmosis.

Dr. William O’Connor: I noticed that anecdotally as well because of that cross-pollination you’re talking about when you’re having interdisciplinary teams that are able to connect a little bit easier. There is some learning that goes on and I think it certainly benefits that patient you’re taking care of at that moment. But I think it also benefits subsequent patients that you treat because you’re gathering those learnings and learning more effectively from your peers.

Dr. Kai Romero: Yeah, even just things like tolerating silences, you know, not a strong suit of mine historically. There’s a silence, I’m just going to jump in there, fill it with whatever. And watching some of these social workers and chaplains just wait and wait, and then you don’t want to be the slow mule that jumps in. So then you wait and incredible things can happen when you actually give some patience enough space to actually talk. Like they may need 20 seconds of silence before they feel comfortable or ready to engage. And if it weren’t for watching some of these people, I would never find out about that because I’d be too busy moving on to the next thing.

Dr. William O’Connor:  Jumping in, yeah, same for me. I could learn from them as well. What’s on the roadmap for you and By The Bay Health for 2023?

Dr. Kai Romero: So I think one of the major things for us is in addition to all healthcare organizations, kind of ongoing discussions around what we look like as an organization in terms of how remote or not we are. I think we’re really looking forward to the opportunity for expansion of our palliative care branch. We do home-based palliative care, which is not as common as you might imagine. And figuring out how to make sure that we can expand in our territories where there really is a lack of access for many home bound patients to that care. And then additionally trying to grow our hospice in some of the territories or counties where we already exist. One of the things that has happened as a result of the pandemic has been kind of just big shifts business wise in the hospice space. So many nonprofits in our region are either struggling or going out of business. And so recognizing that a big part of the next phase is figuring out how do we remain not only a kind of market leader in our territory, but how do we also partner with other nonprofit hospices to make sure that the community has broad and robust access to this. It’s something we care deeply about.

Dr. William O’Connor: Well, it sounds like you’re set up for an exciting 2023.

Dr. Kai Romero: Yeah, I think so. I mean it’ll be interesting to see because across healthcare, everyone has dealt with pandemic fallout except for insurance companies. Somehow they never deal with the fallout for anything. They’re thriving, doing really well post record profit. But the rest of us have to figure out what the world looks like. There’s a huge conversation around hospital at home, the use of telemonitoring in order to care for basically patients that qualify for hospital level of care, but could theoretically with tons of technological support be monitored in the home. How does that dovetail with home health? Who manages those patients? I think there’s a lot of questions being asked about where the right place for medically vulnerable people might be at various points in their life. And I certainly think an organization like ours is gonna be a part of that conversation.

Dr. William O’Connor: Dr. Romero, it’s been fantastic having you on the show today. You’ve been very generous with your time. Thank you very much for joining us and we will have to have you back on the show soon.

Dr. Kai Romero: Absolutely, thank you so much for having me. It’s been a pleasure.