EP65 Lifespan Project with Dr. José Pagán and Kelley Akiya

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I AM GPH EP65 Lifespan Project with Dr. José Pagán and Kelley Akiya
EP65 Lifespan Project with Dr. José Pagán and Kelley Akiya

Alexandra Arriaga: Welcome everyone. How are you doing? I have Kelley and Dr. José Pagán here with me today. Can you guys please tell us a little bit more about what you do here at NYU?

Kelley Akiya: Okay. I'm Kelley Akiya. I just finished my first year as a PhD student. I am in the Health Policy and Management concentration and it's my first year living in New York, which has been a blast. Previously I was in Oakland, California so I moved across the country to come here and I've been working with José this whole time, since I got here. It's been great.

Alexandra Arriaga: [Kelley] Congratulations on surviving your first year as a PhD! How are you, Dr. Pagán? We know you a little bit better, but please.

Dr. José Pagán: Thank you for the invitation! So, my name is José Pagán. I'm chair of the Department of Public Health Policy and Management here at NYU, at the College of Global Public Health. I've been at NYU actually two years. This is the end of my second year, and in New York about six years. Because we have a PhD program in Public Health Policy and Management that is relatively new, to me it's nice being able to use and to be able to share the stage with Kelley, one of our first PhD students since I've been here.

Alexandra Arriaga: Today we have a really interesting topic. We're going to be talking a little bit about social determinants of health. And for those listeners that might not be familiar, let's try to explain the term “social determinants of health”. As a student, one way that I like to think about it is, in those cases in which maybe health is isolated from the social context of an individual. So for example, when we are talking about Medicaid. Medicaid can pay for a visit to the doctor, but if the patient doesn't have transportation to get there, Medicaid does not interfere on that, right? And so, how would you define social determinants of health and why do you think that these determinants are playing such an important role in improving quality of care?

Dr. José Pagán: Social determinants of health are basically those factors that impact your health that are outside... What we think impacts health in terms of, for example, in the healthcare delivery side. So many people think that health care matters a lot, and it does matter, but it turns out that health care may impact 20% of your health outcomes and so if you want to address health issues you have to then think about not only that people have access to health care, they can go to a doctor, they have access to emergency services and so on, but that they also have... You have to worry about things like where do they live? What is the neighborhood that they live? How are the housing or conditions? Do they have a job? Do they have transportation and so on. And basically what's going on now is that because we're moving away on the payment side for health care. You mentioned Medicaid. Since we're moving away from what we call a fee for service system, where you pay for every service that you receive. You go to a doctor, somebody gets paid. The doctor gets paid and so on. People are paying more attention now to social determinants because the system is moving more towards what people call value-based care and managing, for example, the cost of care for a population or a person. So if I know that your health, what drives your health is the fact that you have a nice place to live, a good meal, access to all those things that make our life pleasant and nice, and impact our well being. If we can address those issues and that has an impact on healthcare, then we tend to focus on that and there's increasingly more interesting addressing social determinants on the healthcare system side.

Kelley Akiya: Yeah, and I would just add that for me, one of the things that got me interested in social determinants of health is the role it plays with some of the disparities and inequities that we have, because I think when I was first an adult and went and got my public policy degree before I came here and that was before the Affordable Care Act. So, it was a while ago, and everything was about access, access, access. And if we could just get people access to insurance, access to a provider, access to mental healthcare, we could have good health for everyone. And I think that what we've learned is that those things are critically important and unfortunately we're not there yet as a society. But that it wasn't enough to get the same outcomes for everybody and give everybody a chance to be healthy and that it turns out that addressing some of those social determinants of health have the potential to close some of those disparities that we see. And in some cases it makes a lot of sense to do so, because it can be what we sometimes call low hanging fruit. Sometimes you can make some small changes to people's access to resources and link them with social services and you can get a lot of improvement in health. Other times it's more complicated and more complex. But that's what got me more focused on what happens outside the healthcare system when we're thinking about how to have a healthy population.

Alexandra Arriaga: That's interesting.

Dr. José Pagán: Yeah. I was thinking about a few examples on this that you may find interesting. For example, there's a connection between how much you sleep and cardiovascular disease. Where people that don't sleep the recommended number of hours, which is going to be somewhere between seven and eight, have worse health outcomes. It turns out that sleeping too much is also bad for you, by the way.

Alexandra Arriaga: No.

Dr. José Pagán: Way too much, way too much. But what people don't realize is that maybe the reason some demographic groups don't sleep as much as others, I'm talking about here, some minor populations for example, they sleep on average less, maybe because of the type of jobs they have. Because they may work shifts, like night shifts and have jobs that do not afford, do not allow you to sleep as much as you can. So it's an issue of health but it's also an issue of how do you deal with those working conditions and that's sort of like the mechanism to address the health issue. And there are many examples like that connected to the neighborhood where you live and how exposed you are to pollution.

Kelley Akiya: Or the presence of violence, or the presence of noise. All those stressors..those are just some of the ways in which these sort of every day things that we don't think about as health, but we just think of the circumstances in which we live may really impact our health and then our health care needs. And that drives up costs as well as poor health outcomes.

Alexandra Arriaga: Yeah, and I feel like that's more a modern public health perspective. I feel that for the longest time everyone was just focused on what happens inside the hospital. And I've started to realize that most of the impact comes from the prevention, from the being aware of the social context of people. And so, you're doing research on this area, correct? I would like to congratulate you, Dr. Pagán, because you received the Rochester Grant.

Dr. José Pagán: Yeah. We were very lucky to be funded by a program from the Robert Wood Johnson Foundation called Systems for Action and we've been working on this project for about a year, and over the last few years I have built a relationship with partners in the Rochester area that do all sorts of interesting work. One of them is an organization called Lifespan of Greater Rochester. So what Lifespan does is they coordinate social services for people in the community, in the Rochester area. So they coordinated care in unique ways. And one of the things that they did is they decided what happens if we put care coordinators and social workers in primary care practices in the area? So typically, you go to your doctor, and your doctor notices that you don't have transportation services or you need meals delivered at home. That doctor would have said, "Okay, talk to this community organization that is going to help you coordinate that.” What they are doing is they are saying... Yeah, they don't need to give you the referral, the person is right there. So the referral is done right away. And they collected data on that so that our role has been mostly from the beginning to look at that data on hundreds and hundreds of people that they have served, and then they work with an organization at the local level that collects data on hospitalizations. They link the data, the social services data with hospitalization data. And it's incredibly complex to get the data and combine it. And then they give that data to us, and we analyze the data and we're able to tell them basically, this is how your program is impacting hospitalizations and emergency department visits. The hospitalization may cost up to $18000, $10000 to $18000, depending on how complex the case is. An emergency department visit, it could be closer to $1000. So if you can avert, if you can avoid a few of those, you can see how there's some savings to the healthcare delivery system. Medicaid, it could be a private payer, it could be anyone. So that's basically how we got started. So we did that work, and then basically one question that always comes up is like, but you don't have a control group. And how is this working too? And we had all these other questions that come in from the original work you're doing and that's how we put together this proposal and got funded to basically be able to compare if hospitalizations are going down, are they going down due to a program that Lifespan implemented? Or is it a general trend in the area? And is there more collaboration between partners in the community when it comes to addressing social determinants and so on? And we're able to collect data to do that. And actually, Kelley has been working on that component by conducting interviews and thinking about that piece too.

Kelley Akiya: Yeah, so when I got involved, luckily a lot of this stuff had already been planned and everybody had worked out a lot of the intricacies around the data and what the program model was. And I came in and got to interview social workers and physicians and partners who had been involved in the project and it had been going on long enough that they could really reflect on what has been working and what hasn't been working? So that was a really great experience just in terms of getting out and doing some primary data collection which I always enjoy doing. And then, they were really able to articulate a lot of the value, especially on the provider side... Especially for physicians, the value of having a model like this for them, because a lot of times that can be heard to capture in some of the quantitative data and I think some of the things that really resonated with me was how much easier it made their jobs, so it wasn't a project that came in and was sort of asking them to do more. It was really coming in and saying, "Hey, we're going to provide this resource in your office that's going to be good for your patients and is going to be good for you. It's going to free up your time, it's going to free up the time of care managers who can focus more on some of the healthcare navigation issues and more of the clinical side, and give you access to a resource of people who really know the community, they know the resources, they know how to link people to what they need." And they said a lot of the physicians, a lot of the nurses, they weren't trained in those things. And so they would do what they could to help, but there wasn't a lot of confidence that what they were doing was really going to help the patient. And they just felt that they were way more confident in the services that they were providing to their patients and just sleeping... A couple of them said they just slept better at night knowing that people were being much... their needs were being addressed in a way that they couldn't before. Especially in some of these settings, because they have very little time to spend with patients and a lot of the cases are clinically complex and they really need to spend time dealing with those things. So, that was one of the values that sometimes doesn't show up when you're looking at the hospitalizations.

Dr. José Pagán: I think physicians, for example, in a practice are going to know that you have a patient and the patient is not eating well let's say, or he's not having access to meals or doesn't have transportation. You know that that's the solution, but that may not be the way you were trained to solve somebody's problem. You were not taught, "Hey, here's a prescription for a meal, or here's a prescription for transportation." So, you know the problem, and it's going to be very nice. You have somebody sitting next to you that can address those issues. Providers value this because there's so much they can do. They can address the health care side. But not the social determinants side.

Alexandra Arriaga: Right. This is taking care of the whole problem? It's a more holistic approach?

Dr. José Pagán: It is.

Alexandra Arriaga: Yeah.

Kelley Akiya: Yeah. And even just another benefit, and it's a little bit more related to healthcare that came up a lot is, a lot of the like... This project serves mostly older adults, and so a lot of them are just in complex situations where it's a little bit of a question about what's the best setting for them? Whether they should be at home, whether there's another setting that they should be in? What the family situation is? Sometimes what the family wants and what the patient wants can be different. And figuring all of that out is very challenging and it's definitely something a physician can make the recommendation, but they're not going to be able to take the time to go home... Or to the patient's home and meet with all of the family and have repeated meetings over time to come up with a real plan or figure out the Medicaid paperwork in all of those types of things. So I think that was another thing, was just the patient's safety aspect of people feeling like... Because part of this program, is that sometimes the Lifespan stuff will go to the patient's home, and to get a lot more information about how they're living. And that is really informative for figuring out what setting they should really be in that will be best for the patient. And so that's another, again that they felt they had a lot more confidence, and that patients were where they needed to be, and have the family support systems or the institutional support systems that they needed.

Alexandra Arriaga: Yeah. It sounds like such a straightforward idea. I know how complex it's been, but it just sounds like something that should've been done from the very beginning, right? Just making sure that everyone has the entire package, not just, oh you can get to the doctor, but what happens... Can you eat, can you get transportation? It's really interesting that you're looking into this. Something that caught my attention was that, in the case of this project, I believe that you showed me some projections were made, and you were expecting to make $4 for every dollar invested. Can you talk about the business case that this project presents?

Dr. José Pagán: Yeah so, one of the interesting things is of working on a project like this, and part of the reason we are involved in it, and I didn’t say at the beginning that I'm actually a health economist. When you implement a project like this, this was originally funded by the state, and there are also payers in the area interested in this. And one of the questions that they always ask is, if I put money into this project, if I fund the project, what is the return on the investment? What am I getting back? And you can think about return on investment in health in terms of benefit to the patient, health benefits and so on. But you can also think about them in terms of dollar value. In this case dollar value means cost, that you would've incurred: hospitalizations, emergency department visits that you don't incur anymore. Why? Because the program turns out... We have data on about 1000 participants for a couple of years. For some people you look at hospitalizations before and after, and they go around on average 20%, 30%, even higher, depending on the complexity of the case. Three months before to three months after they join the program. So what we do is, we take that information and then calculate the $4 value that you mentioned. For every dollar you invest you get $4 back, means that if I set up a program like this, I'm going to be able to get four times in savings from reduced hospitalizations and maybe visits from a program like this. And then that's information that when you go up to the state and say, you should continue funding this or you go to a foundation, a local foundation, a national foundation, and say, "You should fund this," you're going to get two types of folks listening to you. One is, people that are going to care about the fact that you're improving people's lives.

Alexandra Arriaga: Very important.

Dr. José Pagán: Very important, right? Why wouldn't you be... You are doing this for a reason. Then you're going to have the other person which could be somebody leading that program or somebody that is looking at just dollars and cents and how to maximize that. And they're going to be looking at the other number. Tell me how is this saving money in the healthcare delivery side? So you have to be ready to show those two numbers. So what we do is, we do the research and help the organization. Remember the organization Lifespan does work on a social services side. They understand that component well. We add value because we provide them with information that allows them to make the case of what they do in dollars and cents. So that's basically the main value of that, and the other component that is also interesting is, it sounds simple, but there's a lot of complexity to it. So help them explain what they are doing, because sometimes when you're there in the weeds, it's very hard for you to explain how a program works, how it benefits people when you're offering 30 plus services. We try to simplify that so that they can keep getting funded.

Alexandra Arriaga: Makes sense. And this is not the same as when you increase access, you don't expect additional costs, because more people are getting services?

Dr. José Pagán: You would have some... That's a great question. You ask me a great question. So there could be an increase in cost. I don't think for this population you'll see an increase in cost on the healthcare side, because yes, you may coordinate primary care visits and so on, but the reductions in costs from hospitalization are larger than the increases in cost of primary care visits. But if you're looking at a much younger population, where you don't see that change, if I was doing... If you were doing this for folks in their 20s, then you probably will increase cost short term, but then you'll have huge benefits in the future if you have better access to care and so on early on, and better coordination. Because if they're going to develop chronic health conditions, for example not eating well, and not having a chronic health condition under control, like diabetes or hypertension, 20 years out you'll see the benefit. But that's way, way into the future.

Alexandra Arriaga: Okay, so it does make sense that with an older population you reap the rewards faster because there's better chronic condition management. There's... Okay. Wow. Interesting.

Dr. José Pagán: Yeah, I know, very quickly.

Kelley Akiya: And one of the... I don't know if we have quantitative data on this, but one of the cited benefits from the interviews, they said was that the improvement in disease management and that connection to primary care. And so while that is a cost, it's way less costly than hospitalizations or not being able to stay at home and have to go into a facility because of your health.That connection to your doctor is also strengthened by this model, or potentially is strengthened by this model.

Alexandra Arriaga: Okay. And Kelly, so is there any particular reason why you got involved in this project, and why do you think this work is so important?

Kelley Akiya: I got involved... Well, it was really wonderful, because the project was already up and running when I came along, and it was luck because it fit really well with my interest in social determinants and specifically... And how investments and social services or integration of social services and healthcare can improve outcomes. And then I also have a lot of work experience doing program evaluations. So this is a project that sort of fits both of those things. In addition to being interesting to me personally, I think it was also an opportunity where I could be useful to a team of people. So that's what links me up with that. I think a lot of the things we've been talking about... I think you made a comment earlier that it's like... Well, it doesn't seem like that crazy of an idea to do, but there's actually not the research phase that you would think. Though these kinds of things have been tried, there's a real gap in the literature on showing the outcomes and the cost reductions that can result from this. Especially a lot of the times, we talk about the health which is really important, but I think the work that you all did, connecting these models to a hospitalization, that maybe that's something that is not as well documented and people in the field especially, they want... They see these gaps between the social services and the healthcare and they want to start programs, they want to expand programs. I think this is really an opportunity to showcase a model that has a lot of promise that people can then maybe adapt and replicate elsewhere. 

Dr. José Pagán: You brought something quite interesting to me, which is, the question is why? Why is it that people don't do more work on this, or why is the evidence so flimsy in some ways, even though it sounds obvious-

Alexandra Arriaga: Yeah, that's what I was asking myself right now.

Dr. José Pagán: Yeah. Here's an answer that may not be a complete answer, but I think it's close enough. At least I've noticed that, because I work with a lot of insurance data and administrative data. A lot of it has to do with that, has to do with the fact that there's no way of billing it that is integrated, then the service is like it doesn't exist. So it's very hard to track data like this, and even if the data is available, it's very hard to integrate the hospitalization and maybe visit data that we are talking about with the social services data. It was collected for two different purposes, it's formatted in very different ways. The thinking behind it is very, very different. The reason we have this grant, and we spend so much time on it, is because it's very complicated to understand what a social worker was trying to do when they were referring folks and coordinated all of that, and then combine it with hospitalization data. Which I didn't say that earlier, but the hospitalization data we have comes from the messages that are sent inside hospitals. So when you're hospitalized, the organization that we're working with is called the Rochester Regional Health Information Organization, and they aggregate messages sent within hospitals when somebody is hospitalized. So it's very timely, it's up to the minute, at the same time it's very messy. It's like a little message saying, "José Pagán was hospitalized," and it has a little information so that they could coordinate care. So, it has to do with that sort of integration that makes it difficult to get one set of data that has social determinants and then healthcare utilization in one place.

Alexandra Arriaga: I'm starting to realize how complicated this might be, just because I'm thinking in my head, you get this message and maybe they say the total amount for the hospitalization was this, but how do you disaggregate those costs?

Dr. José Pagán: In that case we don't have the cost data on that, but that's why you work with partners. When it comes to working with that data, what the RRHIO... We call it the RRHIO. What they do is, they get data from the different hospitals in the area, they aggregate it. So if we give them a name, they're going to know, they're going to track down where that person was hospitalized three months before, three months after. And then they take that information and then when they give us the data, they tell us, "This person was hospitalized two months after the program began and three times before the program began." And they'll figure it out. But they're the ones who have the algorithms, for lack of a better term, to figure that out. We would be totally lost, doing it. Or at least I would. Kelley has a lot of experience on this, so she may be able to figure that out. No?

Alexandra Arriaga: So they're standardizing these hospitalization information even between different hospitals? They manage to standardize that?

Dr. José Pagán: Yeah, and then they send it to us, the identified.

Alexandra Arriaga: Of course. Yeah.

Dr. José Pagán: Yeah.

Alexandra Arriaga: Oh wow.

Dr. José Pagán: So it is important to have partners like that that can send you data in a way that it can be easily analyzed by us, otherwise it would've been very challenging. And that takes time, that takes trust, that takes a lot of back and forth. So we've been at this for a couple of years.

Alexandra Arriaga: But it's exciting though that you got the grant and that finally some work is getting done. Hopefully there won't be as many holes in the literature after this project gets done. Kelly, I have a question for you. What has been the most challenging aspect of collaborating on such an important project as a PhD?

Kelley Akiya: I think this has been mostly a positive experience. I think that-

Alexandra Arriaga: Mostly?

Kelley Akiya: No, it really has been. Like I said before, if you can come into a project where you have some background and everybody's figured out the details already, that makes for a really easy experience. But I think sort of the flip side of that, I think the only challenge really has been, is jumping in and then having to play catch up. A lot of the data issues that even José is talking about now, I wasn't in the leads on that, and so, you just have less intuitive feel about what really went into the data collection, the state of the data, helping to emerge together what the problems were. You have less of an understanding of the dynamics between the partners and what their specific history is, things like that. So there's a little bit of jumping in blind, so you have to be a little bit patient, and wait until you feel like you've been brought up to speed. So that was the only challenge because we have really good partners on this project, and I know you haven't really talked... We also partner with NYAM, the New York-

Dr. José  Pagán: Yeah, New York Academy of Medicine, and...

Kelley Akiya: Who I hadn’t worked with before, but there's just a lot of strong partners and everybody works together really well, so that's been great, but I think the only challenge when you come into a project like this, is just trying to catch up and trying to, again, be useful when you're coming in at the end. That was the only thing.

Alexandra Arriaga: And as a PhD student, what advice would you give those who would like to pursue a similar path to yours, and earn a PhD?

Kelley Akiya: Do it earlier than I did. And actually, this is a real piece of advice. I think once you have that idea in your head that you want to do it, if you can, if you can figure it out, try not to list all of the reasons why not to. Just try to go for it and don't be afraid to be aspirational, and think about what it is about either public health or research or maybe a certain method that you think could be done better or differently, or could enhance the work that you're already doing. Push towards that goal, because there's always going to be... it's always going to be hard, it's always going to be inconvenient, so don't sit back on it if it's something that you know that you want to do.

Alexandra Arriaga: Great advice.

Kelley Akiya: Take your shot.

Alexandra Arriaga: That's great advice. What is the key to designing projects that can integrate improving healthcare, while producing a profit? We don't see that very often I feel.

Dr. José Pagán: Yeah, and I think...

Alexandra Arriaga: And by profit I mean-

Dr. José Pagán: By profit you mean, do you mean some-

Alexandra Arriaga: Dollars.

Dr. José Pagán: Sort of benefit in dollars, yeah. I think a lot of it is like you have to have a sense... From the beginning you have to believe the project that you're doing and have a little bit of data that somehow tells you that this will have a benefit. I think the key in this one is, addressing social determinants of health. You can do it at a relatively low cost. You are only deploying X number of social workers and care coordinators, this is not requiring a huge investment in a drug or a device that... A scanning device that can improve people's lives, this is just basically hand holding and helping people to figure out how to navigate this system or connecting you with resources that are already available in the community. So on the one hand you have a service that is much needed, that can be provided at very low cost, and then on the other hand you know this would have a huge impact on people's lives, because if... If you have uncontrolled diabetes, and you don't eat well, this is probably not a good mix. You will end up hospitalized. People are hospitalized for preventable conditions or reasons, and that would be a good example. So if you can address for example meals and so on for this population, you know you're going to have a huge impact on their lives, because the impact in this older population, is going to be huge. If you look at the Medicare population... I don't know if you know this fact, but 20% of people with Medicare... take diabetes for example, end up hospitalized or... I'm sorry, readmitted to a hospital. So you have very high rates of hospitalizations for this older population, especially people with multiple chronic conditions. So anyway, it's a combination of those two factors.

Alexandra Arriaga: I think that's really interesting that you mentioned those two factors. I agree. I would also like to know, what are some key elements to writing a successful grant proposal?

Dr. José Pagán: I'll answer it in terms of grant proposal, and then I would say something about why it's always a good idea as a student to be involved in grant related projects early on, because it is an art. So the success to it, I think a lot of it is like, I tend to think about small ideas and think about one question that I want to answer. Keep it very simple. If you're working with community partners, then you try not to get into a very complex problem. You start with something very simple, and then you try to understand if you're partnering with organizations on a project like this, you have to say, "Okay, I understand all the data that they have, what drives them, what kind of information they have, where do they want to go." And then you start with something small and build trust. That allows you to collect some preliminary data that then you use to then get a grant, or get a larger project funded. Then their technical aspects of how to write grants, that is an art basically. And that art, you only... The best way that I've learned this is by making sure that I early on spend time with people that know how to do it. And then I watch over their shoulders on how they did it.

Dr. José Pagán: And I picked up a lot of ideas from that. So, if you're a graduate student, and somebody invites you to be on a project or be involved in a grant, see how they do it, especially people that have a track record of doing it. See how they do it. Because it's very accumulative. I've been at this for more than 20 years, and I can tell you that every time, in every project I learn something new. And over time, I would get rejected so many times. It was not even funny. For years.

Alexandra Arriaga: Ah.

Dr. José Pagán: Yeah, because you strike out a lot. But over time, then that... If you keep doing the same thing, you're going to keep striking out. So you have to learn from others, watch over their shoulders, what are they doing right, and then incorporate those elements. And over time you develop a body of knowledge that allows you to write good proposals. You've worked with proposal writing before, right Kelly?

Kelley Akiya: Yeah, not on grant writing, but yeah, on proposals and... Yeah, I think I've learned more about what not to do. So I think yeah... Which I think corresponds well with what you were saying. I think working with partners is key. Working with partners who are good at what they're doing, because it can be tricky if you're using a proposal to build something up, maybe that they haven't done before. Or if you have partners on a team that don't maybe get along with each other, it can get really tense. But I think since public health is very applied, especially when you're talking about the policy and management, I think partnering with people who are in the community or partnering with people who have data or who have working data, is really key, instead of trying to invent it all in house in academia. I think that that is really helpful. I think starting as early as you can, getting as many people to read what you're doing. Putting your ego aside. You have to put your ego aside so that you can let people in and see what you're doing and help, but you also on the other hand, have to kind of channel your ego, because you have to sell yourself, and you have to sell what you're doing.

Alexandra Arriaga: So like a good balance?

Kelley Akiya: Yeah. You want to really sell what you're about to do, so that people have confidence that you're going to do it, and they're going to give you the money.

Alexandra Arriaga: So you have to be like a humble, confident individual?

Kelley Akiya: Yeah.

Alexandra Arriaga: Okay.

Dr. José Pagán: It's an art. At the end it's an art.

Kelley Akiya: Internally you've got to put your ego aside so that everybody can partner and collaborate with, and externally you have to be just like, "We're the best, and we're going to revolutionize," whatever it is you're revolutionizing.

Dr. José Pagán: Yeah, and that's experience. You pick that up with experience and... I remember that I spent time with a few investigators that had a very good track record of writing grants, and I would compare the way that I would write grants with the way they did. And basically that's where I picked up ideas.

Alexandra Arriaga: Yeah.

Dr. José Pagán: On that they... Like for example, a lot of work went into designing. Sometimes you're so focused on, okay, you have to write 12 pages or 10 pages, or 15 pages. In the end, who cares? What matters most is, do you have a good idea? And you spend a lot of time on that good idea. After that, the rest are the details. So the 12 pages, you shouldn't be worrying about the 12 pages you've got to write. You should worry about the idea that you're developing... The 12 pages, you may not sleep for a few days, but you'll get it done once you know what you want to do. And I've seen that. I had a project once, funded by Medicare, and it was $7.3 million grants, and it became-

Alexandra Arriaga: Oh, just nothing.

Dr. José Pagán: It became... And it was an idea that we had a team, that we thought about what each wanted to do, and I put into a piece of paper, and say, "These are the main points."And I then went around and I said, "Is this what you want to do?" And everybody said, "No, that's not what I want to do. I want to do this." "Okay, tell me." And everything was into less than a page. And once that page was done, everything else was easy, because then all partners agreed. And many nights we worry too much about... All the other work that goes with it. Anyway, we should do one session on this and just that.

Alexandra Arriaga: We totally could. You were talking about something, and I was trying to put this little parcel in my head, at the beginning you said, there was a hole in the literature in this topic. And then, I worked on a grant once as a research coordinator, and the PI at the time, the principal investigator, I asked him the same question. How do you get so many grants? Basically was my question. And he told me, "Well, we always make sure to base our research on some good evidence, something that already has a solid base." 

Kelley Akiya: And I think I should clarify it, when I said there's a hole, it's not a complete hole. People know who have been studying social determinants, but finding evidence based models that has really been shown to work. They're out there, but it's like a little patch work of somebody's tried something over here, somebody's tried something over there. There's a lot of initiatives right now, and investment going on in these types of things, but it's not as well developed as the literatures you might expect, given this idea seems pretty intuitive.

Dr. José Pagán: I think that part of it is like how fast can you learn about what's known. It's what folks have written about experts in the field. Sometimes you'll find documents are synthesized, or summarize what's known at that point on that topic. And then, on the practical side, do the gaps that you have identified, are they consistent with what you hear in the field. So if it's something connected to social determinants or you're working with community based organizations, do they agree with you or do they think like, "why do you want to study that?" Then you probably should stay away from that topic. It doesn't make sense to have... If you're not meeting a need, then there's no point of studying. One thing that I've done before for example, just for students, that works. Here's one of my favorite tricks. If you are interested in anything connected to health or healthcare that there's a report from the national academies, they put together these committees. So let's say, your... That's the way I got interested in insurance, and how to cover the uninsured. The national academies will put together this huge reports that typically will summarize everything that is known up to that point in that topic. And they have a panel of experts, and consultants and all of that to get that done. They'll identify... they'll make some recommendations, and sometimes they'll even include research caps or questions that they spend basically a year trying to figure out, and they don't have an answer to it. So they're basically putting it out there for somebody to latch on, look at them and try to analyze. So the way that I did some work connected to coding and insurance, was basically looking at those reports and spending many hours reading them and so on. That's one way of learning about a topic.

Alexandra Arriaga: You're going to laugh, but I was literally going to ask you, how do you identify a problem, and what could be the first step to fixing it?

Dr. José Pagán: Yeah, that's sort of like looking at what's known about the topic. And you may identify topics along the way. Your question, it's more like, I just look around and I... The environment that I'm in is what gives me interesting ideas. The insurance question that I told you about that I was interested in at some point in my life, was I lived in a city where a third of the population was uninsured, and I was very curious as to how that impacted access to care. For me that had insurance and everybody else in the community, and the services available to everyone. So it was almost like a personal experience. I think that motivated me to be even more interested in that topic, because I had family members without insurance, I had friends without insurance. That made me even more interested on the topic. So you could say the same thing about diabetes. If you have... And if you ask around and talk to different academics, you'll see that many times they're interested in topics because of something that happened to a family member or something that they experience.

Alexandra Arriaga: Yeah, absolutely. Well, thank you so much. I feel like we've-

Dr. José Pagán: You're welcome.

Alexandra Arriaga: We've learned a lot, and it's definitely an interesting topic. We don't usually talk about projects that can give you a profit, or even what would say quantitative research on something like social determinants. So thank you so much.

Dr. José Pagán: Thank you Alexandra.

Kelley Akiya: Thank you.