What Is Care Management And How Does It Affect Home Care Services? (Catherine Vergara Pt. 1)

[ 00:00:15 ] We're going to go ahead and get started. Welcome everyone to Home Care U. I'm Miriam Allred, one of your hosts. I want to start off and say Happy New Year to everyone. This is our first episode or session or class. We call them all of the above in the new year. So, thanks for joining us. I hope everyone's having a great start to their year. Whether you believe in resolutions or goals or, you know, themes for the year, I hope everyone's starting off strong. 2023 was awesome. Also bumpy for many of us, you know, still coming out of the pandemic. But let's all just put our minds to it and take it one step at a time and have a great 2024.

[ 00:00:58 ] Thank you to all of you, our guests, our listeners, our subscribers, everyone for the support of Home Care U over this past year. Many of you have probably seen the announcement. We became the number one rated podcast in home care in 2023. I am hopeful and anxious and excited that we can outdo ourselves in 2024. But I really, this wouldn't be possible without all of you, without our guests and without all of our listeners. So, we hope to start the new year off with a big one, And I think we're going to do just that today. But I hope you all will stick with us and continue to give us feedback and insights and attend these classes in the new year.

[ 00:01:38 ] And I really think we're going to have another stellar year full of great insights and information and guests. I want to just call out for any of you that aren't getting the sessions or these classes directly to your inbox. You can go to careswitch.com/subscribe. And join our email list to get the weekly podcast recording straight to your inbox. When you register, I know that's a little bit different. And so; if you want to get these directly to your inbox, just go to thatcareswitch.com/subscribe and you'll get them every week straight to your inbox. Without further ado, I have interviewed most of the top executives in the industry over the last couple of years. And just when I think I can't outdo myself or outdo this show.

[ 00:02:29 ] And I'll admit my bar is really high. I meet someone like Catherine. I've been anxious to get her on the show since I met her back in October. I think you all are going to love her as much as I do. She is, you know, maybe under the radar in home care, but I knew I had to bring her to light here. Out of the gate, connect with her on LinkedIn. She is someone that you want to get to know, be aware of, by following her. So, I am like over the moon to introduce you to Catherine Vergara, who is the CEO of CareFor in Austin, Texas. CareFor is a care management company that provides home care services.

[ 00:03:08 ] So, a slightly different model than what you all are used to, or some of maybe the models that you all provide that are listening to this, but I felt strongly about bringing her on to bring some really unique perspectives and insights to the show. So, Catherine, thank you so much for being here. Thanks for having me. Certainly, an honor. I too was just thrilled to meet you in October. Andrea Cohen had just said so much about you and she's an amazing connector, and I'm glad we were able to meet up. Yes. I also wanted to shout out Andrea Cohen. She was on the show this past fall. She is really a pioneer in home care in the, in the Boston area, but also has served on national and state boards.

[ 00:03:49 ] So she introduced Catherine and I, and I'm grateful to her. Andrea is Catherine's mentor. Um, and Andrea has been an inspiration to me and many for years. So, um, she, she connected us back at HCAOA in October and the rest is history. And I think we've got a lot ahead of us. So, um, without with all that being said, let's, let's jump in. I want you to start telling your story a little bit, your journey to home care and landing at CareFor is pretty interesting and different than most everyone's story is special and interesting to me. And to others. So, I'd love to start here. So, tell us a little bit about what you were doing before and then how you really landed at CareFor. Sure.

[ 00:04:34 ] So, um, I went to school to study to be a pre-med major. I was biomedical science at Texas A&M and my junior year, sort of like the MCAT season, I had gotten ill and needed to pivot and choose something different. And so, I went ahead and graduated from A&M and then went back to St. Louis where I grew up and got a Bachelor of Science. And nursing from St. Louis University. So, I graduated, um, as a young nurse, ready to sort of take over the pediatric world and landed a job in Austin at the children's hospital in pediatric oncology, and just fell in love with the space, the physicians, the pathology, the families, the children, and spent the first seven years of my nursing career building, uh, the outpatient program there.

[ 00:05:21 ] I became a manager as the hospital acquired the program and then started operating and helping that program integrate into the hospital system. And I was kind of trying to decide what was next. I really loved what I did, but it was a little; felt a little like tied in by the bulkiness of the healthcare system. And transparently, I thought I always would be in Peds, but I was approached by an individual that I knew socially, who was an operating partner at this small new PE firm. And they were doing due diligence on this. Founder-led care management business that had a direct-to-consumer home care. Well, it wasn’t I mean, it was direct-to-consumer caregiving PAS side of the business, and they were looking to grow and scale that. And, um, I grew up in an entrepreneurial home.

[ 00:06:11 ] And so that was like interesting to me, but it was very different than what I was doing. But I agreed to the meeting mainly out of just common courtesy; was introduced to the founder. And while I was fascinated with the business, we were. Like, frankly, both kind of mutually disinterested in each other at the beginning. She was like, you're too young. You work with children with cancer. I was like, I've never really worked with the aging population and that's not really my deal. And so, the operating partner kind of saw this all falling apart and he like repositioned the offer and said, 'What do you think about instead of just living elbow deep in it as a care manager, what do you think about like operating and helping and growing and scaling the business?' And.

[ 00:06:54 ] That was super interesting to me. Um, I love. The operations and how things work and run. And I was young. I would just turn 30. I had no children. I wasn't married. And I felt like I was leaving good ties where I was coming from. And it was worth a shot to take a go and get to understand what this world was. I knew nothing about home care. I knew nothing about care management, and um, I said, 'Yes.' So, and that was 10 years ago this summer. This is so interesting. Okay. So, but quick. So, so people understand we're going to focus on care management today. We're going to talk about, like, what it is, what it isn't like kind of demystify care management.

[ 00:07:40 ] Then we're going to talk about, like, care management strategy and how it plays into home care. Next week, we're going to talk about, um, your journey with private equity, like what you've learned, how it's gone. You. You, like you just mentioned, came in with private equity already involved. So just so everyone's aware, like that piece is super interesting. And Catherine's journey is like kind of unlike many. And so, we're going to talk in depth about that, but I want to clarify, like today's care management next week's PE. So, um, come back next week. If you're really interested in like in the PE component before we jump in though, I do want to like you to highlight the org chart just so that people understand when you came in, you mentioned the founder, you mentioned the firm, you mentioned you doing operations, just like super quickly highlight, like what the org chart looked like then.

[ 00:08:28 ] And now just so people understand like the hierarchy. So, I had not, I mean, I had been a floor nurse turned clinic manager and operator. I had never been in the private sector, and I had never operated a business. And so, while I had what they felt like was the DNA to learn it and go do it, I had never done that before. And also. Had. Never been in the industry that I was stepping into. So, for the first three years, the operating partner from that firm acted as the COO. I was director of ops and title, and our founder who had been a solo practice just took the title of founder. She was, and still is, transparently very involved in the organization, but from an org chart, like no one has ever reported into her.

[ 00:09:20 ] I reported up to the COO, who's an operating partner with the firm. And then all of the hires that we brought on within the organization reported into me. Founder has a board seat, certainly an integral part in a strategic partner and thinker, and someone who I have learned a ton from, and she's been a mentor to me. And I certainly value her opinion about the direction of the business, the way we provide services, but no one operationally has reported to her. Uh, and I have never reported to her. Uh, from an org chart standpoint. Okay. Perfect. Yeah. I just wanted to set kind of that foundation of like who's where, so people understand, um, let's get into it. And the way I want to start is talking about your service line.

[ 00:10:06 ] So you are a care management company, but you also do home care services. You also do guardianship and planning. Tell us just briefly about like that structure. And if you can also like kind of ballpark numbers, like 80%. Is X 20%, like kind of a breakdown of like numbers. So, people understand those service lines and then we'll get into and talk about like how they feed into each other. Sure. Um, so the home care side of the business is really 80% of our revenue, which is interesting because what we really market is 20%, the 20% in the care management that drives the home care. So, within the care management, we don't historically. Break it down on a number standpoint, but within our care management, we serve about 180 clients and about three dozen of those are guardianship clients.

[ 00:11:04 ] So those guardianship clients receive care management services as well. A lot of them receive home care services, but about 36 of that one hundred eighty, we serve as legal guardian for that's through the state of Texas. We're a private professional guardianship program governed by the judicial branch. And we, you know, appear in court in various counties across the state to serve in that role. Um, the planning is just a component of our care management through our guardianship services. Really, it grew into a service line where we serve as medical power of attorney for individuals who either don't have someone to serve or need someone to serve secondarily. And out of that medical power of attorney program because people have capacity when they're naming you. Yeah.

[ 00:11:52 ] So there's a huge need to plan and for people to understand what their options are and to express their wishes while they can so that when they can no longer speak for themselves, whether care for serving in that role, or they've named an agent, that agent has a guide for what they are. They want that they've already expressed. And so, the guardianship work has been an interesting part of our business. It's time-consuming, but it's certainly not the bulk of our business as far as the types of clients we serve. Yeah. Yeah. And so that has fed into the planning component of our services as well as the medical power of attorney and just the general helping people understand, yeah, it's a lot harder for people to honor your wishes if they don't know what they are.

[ 00:12:34 ] So while we can, let's have those conversations and begin to map out knowing that things change and you pull different levers at different times, but that's been a really unique service. I think that we've offered that has provided a lot of peace of mind for people when they think about aging and planning. And, you know, talking about, frankly, taboo topics around a lot of family members. As an industry for many years, I would say maybe more so over the last decade, we've talked a lot about like whole person care or patient-centered care. Home care is an important component to that philosophy. Care for has a much broader scope here of really owning. Like most of the pie per se with these different service lines, just explain, you know, the founder's vision, your vision of this like whole person philosophy and why it's attributed to your success.

[ 00:13:33 ] Yeah. So, when I came on, you know, I took a deep dive in care management. I took a caseload for two years and did, during those first two years are very formative of the, you know, the vision and the culture and the mission of who we. Who. Okay. Were, was created to be, and who we were going to continue to be going forward. And what had always been, you know, number one North star was patient first and you know, the uniqueness of a care management model where you're working directly for the patient is it stands out in the healthcare space because that isn't always, well, it should be centered. It doesn't always stay that way. And the way that care management allows us to put the patient at the center of the conversation, you know, home care for us is a solution in a lot of ways, which is why we provide that service.

[ 00:14:23 ] It's an amazing solution to stabilize cases, to allow people to age in place or to extend their time living in whatever level of care that they're in. But for us, home care is not the center of the wheel. It's potentially a spoke that comes out of that center and having a care manager in the middle of that with the patient to make sure that you are directing care. Yeah. And making choices and navigating the road in a way that honors, you know, their dignity, their preferences, their wishes, and provide some clarity, understanding, and knowledge behind whatever complexity they're facing, I think has been really important for us and has been helpful as we think about who is caring for what kind of services do we offer?

[ 00:15:06 ] Who do we want to be keeping the patient first has allowed us to say, you know, does this add value to the continuum of care for them? Yeah. So how do we either provide ourselves or build strategic relationships to make sure that we can make that a seamless addition to their care plan or a seamless transition into what's next for them? Mm-hmm. Mm-hmm. Great. So, let's dive into care management. I want people to understand it to the, to the level that it warrants. I want you to speak from the lens of some home care providers today. Okay, a degree of care management, whether they call it that or not, or offer it as like its own service line.

[ 00:15:53 ] That's a really like mixed bag across the industry, but I think it's really important that people understand like what care management is, what it isn't, and, you know, like demystify some of the common misunderstandings. So, let's start here by explaining like what it is, what it isn't, and helping home care owners understand. Understand what it is and isn't. Sure. So, you know, home care management either means 10 different things to 10 different people or nothing, because you have no idea what that means. So, there's a blessing and a curse to it being unregulated. And if there's no, you know, federal standard to say like, this is what this is. We do have a wonderful resource in the Aging Life Care Association. And I'll just put a little plug in there.

[ 00:16:46 ] If you want to learn more about the national organization that care managers belong to, aginglifecare.org is a great place to go to just read more about ethics, standards, resources, and who our national organization is. That's where care managers go to be a part of a national organization. But care management as a whole, as a whole is generally an, an organization that's sometimes an individual or a collective group of people that have some connection to the clinical or aging space. And that's so broad because there are so many different types of care management firms or solo practices providing care management. There's usually a clinical component at CareFor. We are largely clinical, and nurse driven. We have one social worker, social workers, oncologists, PT, OT, ST, people that are in the mental health space.

[ 00:17:47 ] So there's lots of different types of providers in the human health services that are providing care management. But what I think is important to know is that, or sort of like what care management is not, it's not so much that like, what is it not, but it can be so much more. It can be so much more than what people think they're offering. And it can provide such an amazing solution for families. If you will connect with a care manager or build a care management line that has the capacity to go deep and to go deep, you have to have the time and space and energy to deal with the clinical and social complexities that come with folks in the aging, mental health, disability, illness, change space.

[ 00:18:42 ] So I think, you know, care management has a lot, means a lot of different things to different people. For me, it's complex problem solving for the socially and medically complex. But I think a lot of agencies say they offer care management and while they are offering a piece of it, if they structured it as its own service line, I think they could offer it in a much more effective way. It's not that what they're doing isn't effective. It's just that they're offering care management. It's just that they could be doing a whole lot more to add value and to really be critical in the problem solving that's going to stabilize the case because home care as a service line isn't structured to have the bandwidth to truly deal with the 90,000 other things that are going on, not only in the home but within the social structure of this family.

[ 00:19:41 ] So I think that's a really important point. I think that's a really important point. Outside of providing the care for that individual. And there's just so much more complexity around medication management, appointments, compliance, discharge planning, DME, equipment, home modification. Do we need to move? When do we move? Why do we move? Who goes? Who goes with them? The disease progression, education. And then, you know, you've got the family dynamics of not everyone's on the same page. And that's, usually like to say it lightly, if it's just generally mildly not getting along versus having, you know, very strong, different opinions about what to do with their loved one. And at the end of the day, you hope everyone's wanting the best thing for that person. But in crisis, everyone kind of has a different way of dealing with it.

[ 00:20:29 ] And to have someone that has the time and energy and space to enter into that scenario that has experience, that's not, you know, emotionally connected to the situation, that is a problem. And I think that's a really important point. And I think that's a really important point. And I think that's a really important point. And I think this space and has the time and bandwidth beyond just figuring out how many hours of care do we need for this individual this week, and here's the two-week schedule or whatever, maybe. But to really start to dig into those other problems and solving it, I think it just, it requires more bandwidth than, you know, the structure of a home care company can provide. Mm-hmm. I want to insert a disclaimer here. The primary audience of this podcast,

[ 00:21:11 ] our home care owners operators leaders this is by no means uh an endorsement or a call to action of you know every home care owner needs to provide care management services I’m just you're not coming across that way but I just want to vocalize like that's not our objective here it's more to educate on what care management is later on in the episode we'll talk about working with care managers as a referral source um so I just want to like throw that disclaimer out here so people understand like the objective here and what we're trying to accomplish and know that this isn't like a you know every home care provider should be doing care

[ 00:21:46 ] management like Catherine is saying it is extremely complex and most you know small to mid-size home care providers aren't equipped to provide this level of care or this this service offering and so there's a lot of there's a lot at play here and we just want you to understand like what it is and what it isn't so that you can um potentially incorporate it down the line or you know and or partner with other care management care management providers in your area I want to dive a little bit deeper here you just did like a really good kind of overview what it is how complex It is who it's for, etc. I want to talk about who the care managers are like you know, talk about you know, you have I think like 10 or 12, who are they and what qualifications do they have to be care managers just because I'm curious like who they are and how they're qualified.

[ 00:22:39 ] and just so you're prepared then I want to talk about like who the clients are I know you just mentioned some kind of criteria of who would need care management if you can get a little bit more specific, you know, who are the clients that need care management services and why, so start with care managers that will work to clients yeah, so the care managers that care. For are largely nurses, bachelors prepared, registered nurses. I have one uh, social worker that's on our team that has been a tremendous asset. But our business was nurse founded, nurse led through me and just the acuity and the types of cases that we have built our business around are very medically complex and have a strong need for a strong clinical medical background care management as a whole.

[ 00:23:26 ] I think lots of organizations have usually a clinical nurse on staff; some are largely clinical like ours. There's usually a lot of social workers that are involved in the care management, but physical therapists, occupational. Therapists, folks that have been in the senior space for a long time, folks that have backgrounds in gerontology, master’s in psychology, folks that have an affinity towards working with the aging population are who care managers typically are. There's sort of like a beauty in the diversity of the types of folks that have that provide the management service because the reality is the types of needs that patients have are very vast. I mean, there's three or four firms in our area that do similar work and the makeup of the care managers within each organization is very different.

[ 00:24:22 ] And everybody kind of has like their own little niche on the types of services they provide. And those firms are largely primarily care management firms that have partnered with various home care groups. And they have a couple of strategic partners that they usually work with very closely. And so, to your point from your previous comment, at the end of the day, I think it's just really important that home care sees the value of care management, whether you choose to infuse it into your organization or to partner with a solo care management firm. Ultimately, you're getting better outcomes for your patients. And that's why we're all here in the first place. We're here to provide excellent care that provides peace of mind to the aging, injured, and mentally ill.

[ 00:25:05 ] I mean, that's what we do at CareFor. I think in the home care space, everyone's essentially trying to do something similar. So, that's who care managers are. And as much as it sounds like a really sort of vague, 'what could be a lot of people', the reality is it is. It can be lots of different types of people providing, like serving as a care manager. I think that was perfect though. Like you said, diverse backgrounds make for really good care managers. And then you as a company, you have 10 diverse experts, like you can bring on clients with a variety of needs because everyone has like different expertise. So that was perfect. And we work really hard in the intake too, to really understand what the need is, because not only do you want like diversity of background, but you also want to make sure that you're making putting a good fit from personality and skillset.

[ 00:25:50 ] So even though my care managers are largely nurses, they all have a different clinical background that they where they served. I mean, I'm the only one that comes from pediatric oncology, but we have folks that have come from other chronic illness. We have folks that have come from hospice, folks that come from home health, chronic illness, cardiology, rheumatology. Things like that. Our social worker has an extensive background in hospice as well. And then just temperament. You can sort of tell by the background of the individual or the way they're talking or what they say they want and don't want. You want to, you want that to be a good fit because you're really hoping to not have additional barriers in that relationship because what you're dealing with is usually pretty sticky and challenging and stressful.

[ 00:26:31 ] And you want to make that as smooth as possible so that you can actually be effective. Well, and it makes your business like, deep and wide, like deep expertise, but then also wide, so that you can service a lot of different client needs. So again, like I said, I think that was great. Before I had you jump into kind of the client side earlier, you mentioned, if I understood right, you lead when you're marketing care for you lead with care management. So, you're quite literally like leading with care management to go out and find clients. But caveat here, you have such a strong reputation in your market that, to my understanding, most of your business, you're going to have a lot of people that are going to at this point in time. And that's like a luxury that you've built.

[ 00:27:13 ] But I want to talk about who these clients are. And just, I add in that, like you're marketing and leading with care management. So, you're looking for these very specific clients. Who, who are they? And I know that's kind of a broad stroke question, but, and I know they probably need home care, but who is like the, like the ICP ideal customer profile for a care management case? Sure. Well, I, I don't want to state what's, I don't want to understate what's potentially assumed, but our business is exclusively private pay. So that is the market of the clientele that we serve. And the ideal client for us is someone that we had talked about this earlier, that has some level of medical and social complexity and the ability to privately pay for a complex solution.

[ 00:28:08 ] And that looks so different for so many people. It can be consultative where they just need someone to come in with a professional expertise and provide an assessment and a plan and provide a plan of care and give everyone the roadmap or to make a, you know, a professional opinion on what this individual needs. And then, you know, they're capable of executing it going forward. And it's really a one-time consultative service that we provide. We do does, which allows us to be involved with people ongoing because we will start with the same assessment and we will provide a plan of care, but the implementation of it needs someone to quarterback and own the systems, and what we're going to put in place to make this successful. So that might be medication management that we're providing.

[ 00:28:59 ] That might be in-home care that we're providing. That might be a decision on, we need to relocate this individual. And this is how we're going to go about doing that. And it could just be ongoing managing of medications and doctor's appointments and, and dealing with family members and making sure that it all goes smoothly. The levers that we pull are the types of things that we provide for clients because it is patient first and patient centered and based on their needs, ebbs, and flows as the relationship changes and the individual ages or improves or declines based on, based on the need. So, it can be a one-time consultation that then they circle back around when they've had a medical event or an ongoing need.

[ 00:29:48 ] And as, as much as the home care may continue, the care management may come in and out. You know, they need care management to come in and get things settled and make a decision on care, get everyone in place, but their nature of the stickiness of the, of the dynamics, it requires a third-party professional, to help manage and get it all settled. But then once it's settled until there's an event, it's, it's pretty sad. And so, care management kind of takes a back window. We check in periodically, but we're not having an active presence with that family or that individual until then there is a particular event or a change in status or something needs to happen in care and care management re-engages.

[ 00:30:29 ] So at Care4, once you're in, you're in regardless of what service that's being provided, but it's not, um, it's not the same every week. It's not the same every month. Uh, some clients we see annually and some clients we see three or four times a week on the care management side. Okay, great. So yeah, just to recap, like, and it's okay that it's general and broad because that's like the nature of it, which I think is important for us to highlight before we kind of shift gears a little bit and talk about like care management and like the strategy and how it feeds home care and fuels, like your home care service. Like I want to ask or talk about like the billing side of things you bill per minute or per like 15 minutes.

[ 00:31:16 ] I want to talk about like how you bill care management. Cause that's pretty interesting. And then if you can share, um, you're in Texas, um, like kind of like a ballpark range for how much you bill care management. I think that's just interesting for people to understand like how much more or less than it is for hourly care. So, talk about like the billing element, just cause that's interesting. And so, we bill in 15-minute increments. So, teaching clinical nurses that have worked in the hot and insurance funded spaces, how to bill privately for their time is its own episode. Uh, but we bill for our time in 15-minute increments. Our current rate is one $75 an hour. Um, but we bill for everything we do.

[ 00:31:59 ] So we bill for face-to-face time, drive time, documentation time, time on the phone, time on text, talking to family members, talking to their family members, talking to their medical professionals, uh, sitting on the phone with Social Security, uh, filling out a Medicaid application, all of the administrative stuff that is required for us to serve that patient well is billed at the same rate. And in the same way, as if we are filling medication boxes, attending a doctor's appointment, accompanying a client on a, uh, at the, you know, being taken the clients' sitting with them in urgent care or being a part of a discharge plan, um, coordinating all of that being able to participate in their entire world allows you to be more effective in the small tasks that you need to complete.

[ 00:32:45 ] Um, but you know, faxing records and communicating, sending referrals, getting appointments, those types of things, everything we do for the client, we're billing in a 15-minute increment for us at one $75. Okay, great. I wanted to add that because people may or may not know that and not to like scare people out of this, but that is the level of complexity. You're dealing with, with care management, you know, tracking 15-minute increments and tracking and billing for every single thing that gets done. And so, I think that's just, that's a nuance, an important nuance. It's pretty differently than, but I think it's why you can go deep because you can have the personnel to spend the time to do it. So, um, you know, our, our caseloads that our care managers have are based on billable hours.

[ 00:33:35 ] People always say, how many patients do your care? Managers take care of, and it vastly varies between care manager because it depends on the acuity of the clients, they're taking care of. So, they're all billing around 35-ish hours a week. But that looks different for, you know, we have one nurse that carries a deep mental health caseload. Those are much fewer clients because the needs are just really great and become very acute very quickly. Uh, we have a nurse that's really good with the planning and the medical power attorney type clients. That's a higher case. So, um, so it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, it's, they're largely pretty stable. Um, but billing in that way. And I think that's the part sometimes when we say like, 'home care could,' like, if you take a nugget, it's that like from the jump value, the service that you're offering in this way and bill for it in a way that you can actually get in there and solve the problems.

[ 00:34:29 ] Uh, and it's going to make like it benefits everyone. It certainly benefits the patient. It also benefits your organization because, problems are being solved. The schedulers are happier. The caregivers are happier. The patient has better outcomes. And because you have someone that's dedicated to help solving these problems, and you can dedicate them in that way because they're being compensated. Like the business has been compensated for what they're doing. I think this is kind of that first distinction of, of a lot of home care businesses are doing some variant of care management. But I think that, that you just called out, imagine if your caregivers had, you know, these care managers that were really experts in the cases and the needs and all of like the complexity, and the caregivers could focus on just the care, like the difference that would make in your organization.

[ 00:35:22 ] So we're going to kind of keep going down this vein of like how the services support and like balance each other out in different ways in, in kind of the same vein of what we were just talking about around like the billing components. We talked so much about margins and home care and how like razor thin the margins are. Can you speak to the margins of care management and how that influences like the cash flow of, of your business? So, I just pulled 20/23, our care management margin in '23 was 47%. I mean, I'm pausing because that's high. Sure. And so, yeah. What, what does that mean? For like your business as a whole, like your financials holistically, because I don't know if you know, like your home care margin off the top of your head, or if you pulled that, but just what that, how that cash flow influences the business.

[ 00:36:19 ] Yeah. So, you know, 20% of our total revenue is care management. So, we market for, you know, 20%, and that also feeds this 80% of the home care. Our home care margin for 23 was 40%, I think. Um, our length of shift is very high when you market care management and you're serving these, I listened to Becky's episode in December. I, I, I don't know her, but I was really enjoying listening to her, but the way she described her agency was had a lot of similarities as far as like, very boutique, very high touch. We know who we are. Culture is huge. The way we take care of our employees is a reflection of the way we care for our patients. Um, but then, the length of shift for us is 10 hours.

[ 00:37:11 ] And so we carry these; we have smaller volumes of cases that have a lot more hours because you are going after these patients that have very complex problems. And so, the, and their need is great. And so, they need more than a caregiver. They need a comprehensive solution. And while home care is a piece of that solution, they need a broader plan and where home care is a piece of it and care management for us can be a big piece of that broader plan and not so much the answer to the plan, but the one that's going to facilitate the effectiveness and seeing that plan through. Okay. So, you mentioned about 180 clients that you have, correct? And you're saying 20% of your revenue is, is funded by care management.

[ 00:38:12 ] 80% is home care for wasn't always providing home care services, if I'm not mistaken. So, we've always met. Correct. Yeah. Sorry. No, that's okay. So, let's talk about that evolution and how, how you convert care management cases into home care. And then what like that home care evolution looks like for, for your business. Like, you know, does, how does, just how to all, how does that all like coexist, I guess? Sure. So, when I joined in 2013, the business was originally founded in 2000. So, it had been a solo practice for 13 years, primarily care management with a direct-to-consumer home care solution. So there were private caregivers that worked directly for the patients and our business process, the payroll, well, labor laws, joint employment, all the things – as we thought about really looked at growing up.

[ 00:39:07 ] So, you know, and scaling the business to do what we wanted to do and to be able to control the quality of care we were providing; the caregivers needed to work for care for. So, in 2017, we, they, the caregivers became care for employees, but it's a, like, we already had this private network of folks that were, we were providing care management for, and all of those employees basically became our kind of overnight. I mean, we planned for it, but. On October 31st, they didn't work for us. And on November 1st, they did. So, we inherited about, you know, 150 caregivers very quickly. So that is when we became a home care company and started, you know, living the home care, living in the home care world per se, but it's also why we culturally have always been a care management firm because that's the, you know, the origin of the company and home care was, always a solution for our clients.

[ 00:40:10 ] What the business beats for is the care management work as far as being able to get in there and deeply be effective in solving complex problems for these patients. Andrea Cohen's the one that's drug me into the home care space. And it's like, this is a wonderful world, and you need to know these people. And it's been a wonderful introduction and I've thoroughly enjoyed getting to know other operators. And, but when I, when I come, I, all I know in this, this space is what we've built at CareFor, which is not culturally how a lot of home care companies operate. Yeah. It's a less traditional model, but I think that's why we're here is there are a lot of diverse models in this industry and it's people like yourself who aren't typically up on stage or just kind of like, you know, nestled in your market, like just absolutely rocking it.

[ 00:41:05 ] And we want to like surface these really unique, models because there's something for everyone to learn here. And like the disclaimer, it's not that home care needs to do care management, care management needs to do home care. It's how do they coexist? How do they benefit one another? How do they fuel one another? Um, which may be a good segue into, um, like using care managers as referral sources. I know this is like kind of one step to maybe remove from what you're used to, but if you were say a home care provider today, what would your approach be to, go and warm up to a care manager and become, you know, a really strong referral partner to them? What would you do and how would you do it?

[ 00:41:44 ] So I, you know, the website I referenced aginglifecare.org, that's where I would go to find who, who are the care managers in my area and who are the folks that are doing this work. And I would get to know them and understand the types of clients that they're caring for. And I would build that relationship. Anyway, I would build any other referral relationship and say, you know, I would love to, um, you know, be a solution for your clients at the same time, even though we provide home care, there are home care companies in Austin that call us and say, you know, we need help. This is like, what's going on in the home is beyond, uh, the capabilities of our home care company.

[ 00:42:26 ] And our caregivers aren't wanting to go to the home for X, Y, Z reasons. And can y'all come in and provide some care management to help stabilize this case? We've talked to the family. They would like y'all to come out and meet with them. So, I think, you know, there is an amazing relationship that can happen between care managers and home care providers. Care managers need home care. They're largely not providing it within their organization. And it is a phenomenal solution for so many patients that want to age in place or, you know, stay where they are just a little bit longer, or to have some companionship within the community. And I think that's a great way to get them to come out and meet with them. And so, you know, care managers need home care partners too.

[ 00:43:12 ] And with any relationship, when you're making that referral, you're, you are leveraging, you know, the reputation that you've built. And so you want to trust that the person you’re handing them off to is, uh, going to care for that individual the way that you would. I think what's really important between the relationships between that you're building between like home care owner, operator, and that care manager is the level of trust and respect and communication that when it doesn’t go right, you can have a clear and honest conversation because the reality is it won’t at some point. I mean, we’re dealing with people, we’re dealing with, you know, complex situations. And so having the rapport where you can, you know, talk through the situation and, you know, have the opportunity to correct whatever wasn't great, you know, whatever the caregiver, you know, say you had a caregiver that didn't live up to expectation or the patient is saying a particular thing.

[ 00:44:10 ] I think there's sometimes this unspoken like competition or like who's really in charge. Um, and are they going to take my business? Are they going to take it somewhere else? Or, you know, it's more of like a liability, but I think if you can build these relationships where you trust and collaborate and respect each other, and really understand the value that these services bring to the patient, I think it's ultimately the best outcome for the patient. Uh, but they can not only it provide the best thing for the patient, but I also think it will make the service that your company is providing smoother. And, um, you can also be really solid referral sources to each other, I think. Yeah.

[ 00:44:51 ] The way I'm thinking about it, and this is like a clichéé, but it's like providing the full package to the client, you know, like you said, care management goes hand in hand with home care and vice versa. And like you're saying, a care management firm without home care, like their, their care and their capabilities only go so far. And so, it's really like you need, you know, care for has the full package, but if you are a home care provider and want to work with a care manager, you have to like to build that package together. And like you're saying, just establish really clear expectations and services and solutions, like just map all that out. And then, you know, I see it as a way to just like insert your agency, your business into a care management firm, and that you're working so closely together because it's part of the full package that the client receives.

[ 00:45:45 ] So, you know, you're in this position where you're doing the whole bit, but go in, you know, basically like insert yourself as a solution that the care management provides. Like we offer home care, it's through X company, but it's like part of the full package. So, I guess like my question to that, to you is how do you, how do you bundle it? Like when you're, you know, doing an assessment, you're doing an assessment, you're doing an assessment, with a client, like you probably bring up home care in that initial conversation, but how do you like package all of that? Because I think this might help home care owners as they approach care management companies, like insert themselves into that package that everyone can provide.

[ 00:46:22 ] So just very practically, whether they engage in the care management services from the jump, it's on the customer service agreement that they already, that they sign. So, they see it on the customer service agreement. So, whether or not they take advantage of it, day one, or not, they've signed off on it. So, if, and when they do utilize it, it's just a matter of starting. But in that initial call, you know, we're all listening for the perceived need because you want to meet the perceived need and then also help them also understand, you know, the other services that we can offer. And there are people that call us that need a home care solution. And while we can see the value of care management, they don't at the time, or they truly just don't have a care management need at the time.

[ 00:47:11 ] And we need to just provide the home care. And so, we will get that started, but our integrated model at Care for the schedulers are deeply entrenched in the work that the care managers do through our weekly meetings. And then just culturally, the way everyone collaborates, they're also listening to the needs of the client and the, and the types of calls that they're receiving from family members to kind of know like, gosh, they could really do that. And so, we'll get that started. And so, one of the things that we're doing here in the distillery applies to all of the folks that if we really benefit from a care manager. I will also say; you stick with a care our caregivers are very used to having care managers on their cases. And so, they feel as though one is needed for various reasons. They will often call and say, I really think Mrs. Jones would benefit from a care manager.

[ 00:47:55 ] Can someone come out and talk to her about that? And that’s sometimes if it's been a home care client only. Only. Our individual that does you know relationship management business development will go out and circle back and have that conversation, but if they've developed a really strong rapport with their scheduler, they'll have a conversation with them and they'll introduce the service: 'Can I have a nurse come out and talk with you, and get that going?' So, from like very practically everyone likes signs off on the rates for care management and caregiving with the agreement up front. But we talk about our business and solutions; we will certainly identify the two service lines, but we certainly talk about it about as an integrated solution to their problem: whether they need home care or care management right now, both together.

[ 00:48:41 ] One or the other, they also we present it in a way that they know that that's fluid and just because they're using both right now it doesn't mean they have to use both forever or one or the other it can ebb and flow as the relationship goes on I think that was really important for people to hear and like just like what's ringing in my head is this is why it's so important for home care to understand care management because even if you don't take it on yourself and kind of create this integrated model like you're speaking to, if you partner with the right care management firm if you can build that trust and

[ 00:49:13 ] that credibility and you Know provide the value that they're looking for, imagine like the business that can come from this, like you've shared your ratio like that could quite literally equate to like a ratio of like a ratio of like a ratio of like a ratio of like a ratio of like a ratio of even through a referral source if you create you know that level of depth in a relationship and you are the go-to, and you like integrate into their package this could become like a massive source of business for a home care agency when people call me and say you know I'll have a friend call and say my parents are up in Dallas okay well we don't serve the Dallas market. I don't know, I'm not connected to the services there. They say who are the good caregiver, who likes who's the best care giver and who's the best care giver.

[ 00:49:54 ] And home care agency to call. I reach out to the care managers I know in the area and they're saying, 'Oh, such and such company or service' because they're you know they're the ones that I use and that I know and trust. So, people are at times looking to care managers for like, who are who's the best in town for these various services. And so, to build a relationship with the premier care managers in town are going to you know elevate your service and put you Among the folks that are going to be the first ones to be referred, which means it's going to be competitive and most likely they already have those.

[ 00:50:32 ] relationships established, which is inevitable but you know like you just said elevate yourself and your business and you know seek that out as an opportunity if you're in that yeah and there's I mean the industry is growing too and like you know partner with someone that's starting out that's you know trustworthy and that you've built a relationship and you know they're doing the kind of you know they're caring for the kind of people that are going to be in that relationship. and of patients that you think fit well with your agency and you know there are folks that certainly already have those established relationships, but I would say like you know we always say we just need them to give.

[ 00:51:05 ] us one chance well you mentioned even your founder was kind of a sole business woman is that you've referenced that a few times is that pretty common for an individual to have their own caseload that they manage so even seeking out those people may be hard to find but they themselves have like a personal caseload I don't a lot of those folks are members of the um association but the solo there's basically Two camps, there's a lot of these solo practices and then I would say more common the last 10 years are you know firms and groups that have you know have teams of care managers. Uh, but in my in my market there's certainly both: there's solo practices and then there's a couple.

[ 00:51:54 ] that's a good reminder, um, I think where I want to end this and this is putting you on the spot; we didn't talk about this, it's talking about like maybe telling a story or two of clients that you've had that have benefited from this integrated care model, and just the result or the outcome for this this individual or this family. I think this model is unique but it really is the essence of whole person care, which is ultimately what we're all striving for, and I think it's a really good fit even if we can't provide every service or solution, for individuals, home care, and this industry, the post-acute space is striving for that goal, and I think your integrated care model is, you know, really doing a great job of that, and so I want to just maybe put you on the spot a story or two that has resonated with me of an individual or family that has benefited from this model.

[ 00:52:50 ] Yeah, so I think two kinds of come to mind; they're sort of a little bit different. We got connected to this was at the beginning. Of my time at CareFor, we got called about a woman living alone by her neighbor, and she was concerned because she felt like she was declining, and she was living independently, and um she was you know, seemingly confused. Looking like her hygiene was declining, um, but all she knew about was a son that lived overseas, um, and uh, because her husband had previously passed away, and uh, so she was living alone in this home, and she had a son over in Italy, and so, um, we you know the neighbor's just saying like I've heard great things about y'all, and I think you can help.

[ 00:53:38 ] And so, we reached out to the son, and he says, oh, I talk to my mom every day, she goes to the grocery store, she goes, and plays cards; she's out and about, but she calls me every day, and it sounds like she's doing really well. I don't think she has any needs, and um, so uh, we have that conversation with him, and go out to the home, and sort of have a different scenario, uh, that we see, um, and the neighbor continues to sort of see the see the issues, um, but he's just convinced, you know. Well, she calls me, and tells me all these things that she does every day, and you know, I have no reason not to believe her.

[ 00:54:21 ] Um, well, the son's ended up coming back to the states, and staying for a week, and seeing very clearly that she was not doing any of the things that she said she was going to do, those were things she did you know a decade ago. Um, and it was not safe for her to be in her home anymore. But the spouse was basically there to lay eyes on it and was about to go back to Italy and had you known no plans to stay or to help facilitate what actually needed to happen, and there was a big concern about, you know, where do we move her? What do we do? Where do we go? How do we help her?

[ 00:54:58 ] And so the first thing we did once the family saw sort of the need is we immediately put 24-hour care in place to keep her safe. And we were able to provide the care she needed while we continued to get to know her and her son to understand, you know, what is the appropriate plan for her? Is 24-hour care sustainable? And is it the right thing? And that amount of care in the home was not financially sustainable for the family. And she did need to make a move. But again, families over in Italy were here. She needs care, but also needs to make a transition. And so, we were able to help transition her into a wonderful memory care.

[ 00:55:37 ] And we were able to keep the caregivers that she had developed relationships with over sort of that six to eight-week period in the transition. And, you know, she was a very social woman. She was far more demented than her son had really understood. And she never really fully understood that she had even moved from her home. We were able to move all of her things and create her bedroom to look similar to her room from her home. And she basically became the hostess of her new community. And she had a job there and loved greeting people and meeting people. And she kept care. Care was financially sustainable for her for, you know, four to six hours a day, a few days a week.

[ 00:56:19 ] And that allowed her son to have the life he wanted for her to have, be safe, and to live the rest of her years with dignity. But the care management coupled with the home care in that situation gave her immediate safety. And then also gave us the time to build the plan to, you know, provide for her in ways. And, you know, we developed a great relationship with the son and he, you know, continued to stay in Italy and was able to sort of stay up to speed as far as what was going on with his mom. So that's one. And then I think kind of what we, we do a lot of is differing opinions about what the right thing is for loved ones. And so, coming in and making that third-party assessment.

[ 00:57:06 ] We work with a woman, she just turned 99 yesterday, and she did have the means and the ability to age in place. But sandwich generation, you know, child is, you know, raising kids as well, and doesn't really have the time, energy, bandwidth to attend all the doctor's appointments, manage all the medications, manage the household. And so that's a situation where while she's needed a significant amount of care, she's also needed someone to manage the care because there hasn't been anyone in the family to do that. And so, we've cared for this woman. You know, she was part of my original caseload almost 10 years ago. And she's had a very stable, lovely life in her home with her caregivers that have been with her. The whole time.

[ 00:57:53 ] And then care management provides med management and various things for her. And, you know, that whole is sort of a more traditional case, but it's a way where we can provide a solution and then ongoing support for individuals that are certainly, you know, families well intended. It's just a bandwidth and time situation. And they need, they want the home care solution, but they don't have the bandwidth to manage it themselves. And they needed us to come in and help with that. Mm-hmm. Thank you for sharing. I love to just bring it all to life. You know, a lot of times in these episodes, we're in the weeds on like the business side of things and the financial and operations, but sometimes just like paint the picture of what it all means by sharing those stories is really impactful.

[ 00:58:34 ] So thank you for sharing that. I'm sure we could sit here for another 60 minutes, and you could share dozens or hundreds of stories of lives that you've quite literally impacted, changed, saved. And I think, you know, this model is so fascinating and I'm glad that we've given you kind of a platform to share this with others. With others. I'm sure people are going to connect with you. I know we had someone here in the chat, like I want to talk to her after this episode. Hopefully, I'm not signing you up for like a consultative role here but thank you for sharing so openly and so willingly. Yeah. Thanks for having me. I hope people see it as an approachable way to serve clients.

[ 00:59:11 ] And even if it's not something they build just to know that it's a, it's a resource to meet the needs of, of so many people. Absolutely. Well, thank you for giving us an hour this week. We are really excited to have you back next week. Like I mentioned at the start. And for those of you still with us, we are going to talk about private equity and come forth to care for being backed by a, by a PE firm, Catherine working directly with, with those partners. So, it's going to be a, another really interesting, pretty heavy-hitting episode. So, we hope everyone will join us again next week. Catherine, thank you so much for your time, and we'll look forward to having you back next week. Same. Hey, take care of everyone. We'll see you next week.