Please note: The transcript below is automated by speech recognition software and may contain minor inaccuracies.

Jeff Howell (00:00:01): 

Welcome to home health, 360 a podcast presented by AlayaCare. I'm your host, Jeff Howell. And this is the show about learning from the best in home healthcare from around the globe. Hi, and welcome to home health, 360 a podcast where we speak with leaders in home health and home care from across the globe. Today, I am joined by two guests. We have Dr. Joseph Jasser from Dallas, Texas, former senior medical director at Cigna, former president and CEO of dignify health medical founding, former president of the care delivery organization at Humana former chief medical officer at signify health and formal chief medical officer at elara caring. That was a mouthful. Dr. Joe has recently joined Besta healthcare, a leading technology and clinical services organization dedicat to connecting caregiver insights and is focusing on partnering home care, health plans and providers to create value-based population health programs that emphasize clinical quality, improved health outcomes, and personalized engagement. Dr. Joe, welcome to the show. 

Dr. Joseph Jasser (00:01:19): 

Oh, thank you, Jeff. I appreciate the warm welcome men, the kind words. 

Jeff Howell (00:01:24): 

And we also have a man whose fade away jump shot in the Midtown Toronto men's basketball league has still talked about 10 years after his retirement. He's gone on to have mediocre success as CEO of all Eli care, a home health software company that has raised 350 million and employees 500 employees with offices throughout Canada, Australia, and the United States. He's also known in some circles as the second most electrifying man in home health, Adrian shower. Welcome to the show. Well, it's an honor to be here with the most electrifying man in home healthcare. So thank you for teeing that up. Jeff <laugh> I won't say I'm the most, but if you're listening to this and you want to Google most electrifying man in home health, you can see what Google provides to you as an answer <laugh>. So, Joe, over to you, why don't you give us a little bit more background about your career path, 

Dr. Joseph Jasser (00:02:18): 

Be glad to, and good way to open up the conversation. I know you said there's a lot of formers. I I've had a long career made a quick move from internal medicine into administrative medicine and landed over at Cigna medical group as one of my first floor rays into managing clinicians and clinical performance. Right at the time, timing was good right at the time of when HCCs became into existence. And it was a fully capitated medical group with exclusivity to the Cigna Medicare advantage plan and that in the market quickly learned how to manage physician performance and value-based care as well as how to maximize coding and and the revenue capture associated with HCC coding got recruited into dignity, health, medical foundation. 

Dr. Joseph Jasser (00:03:16): 

Interesting story was that the in individual that was that brought me over to dignity. We were negotiating the inclusion of my medical group into the dignity ecosystem in Phoenix. So we became colleagues and shortly after he started recruiting me, I made the jump over to California and ran the, the nation for dignity health in California, that is the ambulatory care system that supports the hospital. We had over 120 clinics across California, five major medical groups. One of which I established while I was there. And grew it from roughly 500 doctors to almost 900 doctors and about four years it was right at the time when, once again timing was good, it was right when hospital systems were diving deep into ambulatory care and growing their footprint as fast as they possibly can. 

Dr. Joseph Jasser (00:04:09): 

We were acquiring groups sometimes in, in the, in the double digits per month. During that four year stretch the tables turned, I got a chance to, to, to to join Humana got recruited over there to run their primary care physician group down in south Florida, as well as the partners in primary care across the country had a great time being a part of the executive team over there, great experience and really got to understand and, and, and appreciate the market dynamics in a very heavily penetrated ma market in that south Florida. And the differences in the dynamics there as opposed to California was very educational. And then took some time off. And then I got recruited by signify health to bring up their chief medical officer the office, the chief medical officer, as well as during clinical the entire clinical infrastructure over there. 

Dr. Joseph Jasser (00:05:11): 

The one thing that was interesting is I left them right in the beginning of the pandemic. It was right as they were unwinding, everything from going in home to virtual as well as prepping to go public and not being able to travel and not being able to get to places made it difficult considering the fact that the entire organization was in New York and they they were moving hard and fast building up the executive team up there. So opted to stepped into home health after that got recruited by AARA. And the move from signify to AARA caring was a natural transition. If you really think about it signify was doing the in-home assessment for Medicare advantage plans and that their, their goal and what I was brought in to do was to build up the complex care management component of it. 

Dr. Joseph Jasser (00:06:04): 

And you know, with the home health being the, the easier entry into complex care management and managing patient conditions in the home. My passion followed me into a Laura and was there for approximately a year and a half as things unfolded and made the move over to vest for the sole reason of giving continuing the passion around delivery of health at home. And the one aspect of the market that I felt that had the greatest opportunity where everybody seemed to be missing was the caregivers caregivers in the home are essential part of the overall healthcare delivery ecosystem and providing them support and clarity and information to what's happening. I think is a great opportunity for us as caregivers and healthcare delivery professionals to really make an impact on a, in the world. So, yeah, that's my 30, you know, what minute and a half career that took me 20 years to get here. <Laugh> but in a minute and a half, yeah, 

Jeff Howell (00:07:09): 

Well, that's, that's a lot of great work there. I'm excited to get a clinician's perspective and someone that's in technology as well. So Adrian, you have a I think it's a master's in photonics and you entered the, the, the mobile world and from a technology background, you you end up coming into home health, give us a history lesson of who is Adrian Schauer. 

Adrian Schauer (00:07:34): 

Well, I won't take you all the way back to my photonics degree <laugh> cause I, that's not that that's not adding much value to my my day to day profession nowadays, but it's true. I have an engineering background. I got into the software startup game back in 2004, initially with a mobile marketing business which then led to a mobile workforce management business. And these were the early days of a smartphone showing up in that hand of you know, every worker that was out there, not at their desk all day. And so we really leaned into the potential to transform how work is done, but we were a horizontal solution. So we were using the same app to manage scheduling and task management and time and attendance for nurses, retail, employ oil rig workers, cops, and it was a good way to go at the market in the early days. 

Adrian Schauer (00:08:26): 

But as markets mature, you really want to get into more of a vertical where you can really understand the day to day of your customer and go much deeper in terms of the value you provide. So that the business at the time vortex connect got acquired in 2012. And then in 2014, we launched a lie care. And you know, in that gap, I'd married a doctor I'd seen a little bit of how care was moving out of the hospital, out of the four walls of the hospital and into the community. And wed we'd had some home care customers at vortex connect. And I really felt like this was a market that had huge growth potential. That was not particularly well served by really a inspir inspirational software companies. And it seemed like a great opportunity to dive in and an area where we could do well by doing good. 

Jeff Howell (00:09:25): 

That's great. So I'm gonna go to the sort of the burning question that people wanna hear about is that March of 2019 Dr. Joe, you actually made a career change shortly after COVID hit. I'm curious to hear from you how things were handled at both organizations that, that you were at. 

Dr. Joseph Jasser (00:09:48): 

That's a great question. And they were completely they're extremely similar organizations had similar challenges, but we're coming at it from the difference of one is as an essential service and the other was a nice to have service. So the way that the market perceived them was different, which was really interesting. And the, that led to the approach of how the companies leaned in on what was happening around them. You know, when, if you take a look I'll, I'll kind of start off with signify you know, signify doing in-home annual wellness visits for Medicare advantage members considered a non-essential service because it is an annual wellness visit. And then obviously going into patient's homes at the time of the pandemic where there was so much uncertainty was not, I deal so their, their position, and as I navigated it with them was to really look at the opportunity of moving majority over into telemedicine. 

Dr. Joseph Jasser (00:10:48): 

So we immediately pulled all the doctors out of the homes as quickly as we possibly could you know, managing the the clients, the, the large payers, the Aetnas, the Humana, the anthems of the world ensuring that the patient population was well serviced. But at the same time, building out the infrastructure and moving the organization to telemedicine which was right at the same time that CMS provided us with the waivers with, for the telemedicine waiver, all types of visits, opening up the, the site of service in the home as a possibility for annual wellness exams using telemedicine. So the, the approach there was a lot different as opposed to when I made the move over to Laura. By that time Laura was, you know, still going into the, their challenge was mainly procuring PPE, ensuring stability, the business, ensuring that the safety of both the patients and the staff through the pandemic so completely different perspectives. 

Dr. Joseph Jasser (00:11:52): 

And, and since telemedicine was a service and CMS came out and noted that although telemedicine can be leveraged in home health, it's not a billable service. So it didn't provide the, the luxury that it did for signify. In other words, the services changed from in home to telemedicine with no disruption for help using telemedicine would add to the workflow and add to the V work volume, as opposed to making it easier for the clinicians that, that brought even more difficulties and challenges, which is maintaining the PPE, maintaining the the ability to go into patient homes effectively, as well as with all the quarantines. There was current times that <inaudible> was roughly you know, you know, 5, 6, 7, 8, 10% of our workforce in some regions were out on quarantine. And in some regions upwards of 25% makes it very difficult to maintain operations in those cases. 

Dr. Joseph Jasser (00:12:51): 

So the, the, the impact was different. The approach was completely different. When you look at the, the business and the ability to, to keep patients safe and keep the caregivers going into the home now fast forward to where we are now signifies back in the home, doing it safely with PPE AARA never missed a step and actually got the pickup. And the, the upswing as Adrian noted care is moving away from the clinic and into into the home. And you know, the, that growth has helped propel, not only Laura, but almost every home health agency into a 2021 challenges still persist still still remain consistent across the board. Now I'll even add that the vaccination challenges are adding another layer of complexity into the overall ecosystem. 

Dr. Joseph Jasser (00:13:47): 

So it's been interesting to see how the different healthcare companies have approached this and talking with a lot of my, I CMO colleagues some at the hospital, you know, they're, they're no different there in dealing with the PPE and then the safety of the, the staff and the safety of the patients, and still maintaining operations when the volume is going through the roof with COVID patients. So it's it's interesting. I'd love, you know, I'd hear Adrian what you kind of heard, cuz obviously you're in a multitude of different areas and see things from a different perspective than I do. Would love to hear what you saw in some of the companies that you work with. 

Adrian Schauer (00:14:28): 

Yeah, for sure. So, you know, one of the interesting things as a cloud software provider is, you know, we're able to see on an aggregated level, what's happening to visit volumes across everywhere we do business. Right. And you know, so we see over a million patients, you know, hundreds of thousands of caregivers across multiple markets and you know, as you would expect, mid-March boom volumes, volumes drop and for everyone, right. Even, you know, if you think of Australia, there were a handful of cases back in mid-March, but you know, you really knew you were in a global media market the way everything moved together. But providers in markets like New York city saw that, you know, that really were were dealing with major outbreaks in that kind of mid-March timeframe. They saw generally the steepest drops on, in aggregate. 

Adrian Schauer (00:15:30): 

Those first kind of 45 days saw 10 to 15% volume decreases. But the New York providers took the, the biggest early hit, both caregivers calling off and clients saying, well, you know, I, I don't feel comfortable having someone come into my home. So there was that initial drop and then the volume of care really did follow a V-shaped recovery curve. So as of end of April volume started to recover and it was a good way to, to see how essential a lot of the the home care really is you know, the skilled and the personal care. So volumes came back in general, but there were some areas that took a lot longer to come back. So markets like Canada, we support a fair amount of outpatient rehab and that had, that was very slow to recover. And in fact I still don't think they're back at prepay pandemic levels, whereas most of the care in the home, you know, be it be it skilled or personal care in general, everyone is at least back and generally higher than they were a year and a half ago when the pandemic hit. 

Dr. Joseph Jasser (00:16:48): 

Interesting. Interesting. And, and Jeff, sorry, I'm gonna ask a of questions, but please do hear you stuff that fascinates me. I met with some folks from Australia the, the CEO and the COO for their largest health plan down there, the United of Australia without sharing names, I'm sure you can connect the dots pretty quickly. Back when I was at signified and learned a little bit about the Australian system, and it'd be interesting to you from your perspective, since you're doing business in Canada and national healthcare system Australia government supported national healthcare system as compared to the us. And I say specifically from a continental perspective because Canada and us can be, are almost one in the same when you look at the impact and the flow of, of people where Australia island almost continent, obviously, but literally, 

Adrian Schauer (00:17:38): 

Literally, literally all 

Dr. Joseph Jasser (00:17:40): 

The world that took the most aggressive stance from a health, you know, from a world healthcare organization perspective of shutting the borders down, shutting everything down. Yeah. How did you see that kind of play out in regards to the volume recovery and the impact of the business? I know we all saw the drop in March and then that kind of a slow, but almost like a V-shape recovery as we finished off 2020, be interesting to see what the others did. 

Adrian Schauer (00:18:06): 

Yeah, so very interest saying Australia has been quite out of sync with north America. So for example right now new south Wales Queensland are in full lockdown, right? They, they took a very different strategy. Their strategy was let's get our cases to zero, right, as you say, it's an island pulled up the draw bridge. Eventually they two country bubbled with with New Zealand, but they really pursued a strategy of we're gonna just contact, trace every case and try and get to infection zero, but at the expense of a really solid and accelerated vaccination program. So they are way behind north America on, on on vaccination. And so now with the, the spread of Delta, the, you know, getting to case count zero is not a really viable strategy yet you're behind on vaccines, they're in a tough spot. So they're, you know, they're literally in lockdowns, like many parts of north America were a year ago. 

Adrian Schauer (00:19:16): 

But there were, there were other times you know, I might get my dates slightly wrong, but you know, if I think of January, February 20, 21, I mean, at least here in Canada, we were on lockdown, Australians were going about their business, right. The only difference was they couldn't come and go from the, the continent, but you know, it was, it was quite a different pattern. So so they had a different rhythm than we had over here in terms of the impact on on home care, because there were never a lot of infections. They had a much lower adjustment, you know, the, the amplitude of the ups and downs were lower. We also support the residential age care sector there. So they had some outbreak in their long term care facilities, but nothing like what you saw over here. 

Adrian Schauer (00:20:19): 

So, and Adrian, do you have any thoughts on why it's such a low vaccination rate over there as well? Well, they they have no domestic vaccine production mm-hmm <affirmative> capability. I mean, they leaned into building capacity to manufacture the AstraZeneca vaccine which then, you know, subsequently many countries moved away from mm-hmm <affirmative> and yeah, they weren't as aggressive in procuring vaccines as, for example, Canada was, and we also don't have domestic vaccine production, but yeah, so, so it was just you know, a strategy and a procurement question now they're catching up, you know, but if you remember that like from December, 2020, when there was an approved vaccine you know, and the us was in its you know, doing 2 million people a day it was very hard to access vaccines in many other places in the world, right. Including Europe and, you know, all sorts of other places. So yeah, we sit here now, you know, anyone know, walk into a Walgreens and get a, get a vaccine. But you know, that wasn't the case not so long ago. And it's still not the case in Australia, they're coming down the age groups like we did here. I think they're only down to, to 40 year olds, you know, as of a month ago. So yeah, it's kind of a, a time warp. 

Dr. Joseph Jasser (00:21:50): 

Interesting. And in regards to the impact of the home healthcare industry, I mean, obviously have they recovered you know, has their, their healthcare system. I know they're, they're awful close when I look at, you know, from a healthcare perspective as, as a physician looking at their case counts and that sort of stuff, one it's extremely impressive, but it, like you say, it comes at a cost of lock and extreme big brother, so to speak mm-hmm <affirmative> which one can argue either way Sweden took a different approach and we all landed in the same place. So, but the, the question is from a business perspective, a home health, you know, we saw that and we obviously the vaccinations almost electrified the entire home, not just home health, but the entire healthcare industry opening back up. Yeah. Now without vaccines down in Australia, is the recovery still happening? Is it not? And the same thing con contrast up with Canada cuz to me, what I'm looking at is fee for service medicine versus national healthcare and the impact the governments did on control. Controling the virus. 

Adrian Schauer (00:22:50): 

I mean, I think there's a, there's a cultural angle that can't be left out of that analysis. So if you look at Canada, we're now at 87% first dose vaccination, 77% fully vaccinated, you know, across eligible, you know, 12 plus adults you know, on the us is stuck. You know, it's more or less plateaued at a lower level on that. So I don't think that's about legislation or how the health system is organized. You know, I think we just in Canada, any I'll speak for Canada first. There's, there's just a greater trust in institutions and you know we're, we're in a similar information ecosystem, but for whatever reason you have cultural differences here for the most part you know, people are just getting vaccinated and going about their business. So it's not a hot, I mean there are pockets, but in general it's not really a hot button issue. You know, no hospital here would hesitate to mandate, you know, to tell their care workers, they all need to be vaccinated and they would see very little pushback from that. So so I think that's generally a cultural difference. Everything I've seen in Australia to date is much more like Canada, you know, as soon as people can get the vaccines, they get them. But there's still a fatigue, you know, lockdown, fatigue, and they're protests now in Australia against the lockdowns. But not much push backing against getting the vaccines. 

Jeff Howell (00:24:31): 

Yeah. There was even a period of time I'm in a suburb of Toronto and for probably six weeks on the province of Ontario was the only place in the world where you couldn't golf <laugh> and the type of golf I play is very socially distance because I, nowhere near the fairway <laugh> well, let's talk about some trends in home health. Maybe if you guys can weigh in on where, where you think were some dominant trends prior to COVID and has COVID helped accelerate or decelerate some of those trends. I know Adrian you've said that a lot of care did about FA five years worth of development in five weeks because it was just all hands on deck and it was a necessary pivot. So Dr. Joe, like you said when you saw this heavy investment into telehealth, obviously these non-essential visits, you can't give a bath to someone virtually, but you can rethink and you can still are to create virtual teams or you can segment your teams into invi teams and virtual teams. Give me a sense of what you guys see as maybe some silver linings coming out of what COVID has done to us. 

Dr. Joseph Jasser (00:25:45): 

You're I'll, I'll let the tech speak first because clinical <laugh> is a different perspective. So I'd love to hear it. Actually, this is intriguing on what, what you're seeing from the technology standpoint. 

Adrian Schauer (00:25:56): 

Yeah, well again, this is where I just have a lot of empathy for anyone trying to run their business during COVID. I mean, we, we went fully virtual and you know, we were already, everyone was on laptop. All of our, every, the app we use was cloud-based. So it was relatively seamless for us, at least from a kinda it point of view. But what we saw is as that wave of, you know, virtualize, everything you can hit the, the home healthcare sector that was a real tailwind for us because you, you know, you need a cloud solution. You can access from anywhere. You need good communication tools that let you collaborate with your colleagues, but in context of whatever you're doing. And we, you know, we happen to deliver the mission critical application for our customers. So all your clinical, all your operational data kinda lives within a lie of care. 

Adrian Schauer (00:26:54): 

And so there's a real acceleration in, Hey, you know, my business process that used to sort of work in the office where my intake person would, you know, hand some paper over to the scheduling person. I mean, that was done. So it was an acceleration of how do I get great workflows mediated by cloud software to run my business and run my whole business? You know? So yes, there were impacts in the field, but I'm talking about every app of coordinating, delivering care and getting it billed and getting it paid. So, so that was one interesting shift just an acceleration of course then as Jeff mentioned, you know, telehealth, remote monitoring you know, COVID screeners contact tracing all the tools you need within your system to be able to operate as safely as possible during COVID you know, got a, got a huge push at the beginning of the pandemic, but then outside of just the technology angle, you know, COVID changed a lot of things in the economy and in the labor force, as well as in how care is delivered. 

Adrian Schauer (00:28:04): 

And so you know, we've now seen an acceleration in mergers and acquisitions in this space because capital is extremely plentiful and available. We've seen continued merging of skilled and personal care. So, you know, Laura being a, being a great example the large providers are seeing the trend towards value based care and and risk sharing and are saying, well, you know, if I'm gonna care for this patient in their home and try and get the outcomes I'm economically incentive to get now. I mean, I need the full range of tools at my disposal, which is, you know, nursing therapy kind of clinical interventions, and then you know, all the assistance with activities daily living and everything that goes around kind of whole patient care. So so we've seen that that accelerate and the most business line agency I think is gonna become a more and more dominant force in the market. And I think the big will continue to get bigger. 

Jeff Howell (00:29:17): 

And just today, actually we saw a huge merger in the marketplace with LH two group. So we're, we're starting to see more deals. And, and I saw a chart recently about there's actually not necessarily more deals this year than there was last year, but the deals are actually getting bigger. 

Adrian Schauer (00:29:34): 

Yeah. Yeah. 

Dr. Joseph Jasser (00:29:35): 

I think Jeff that's that I was gonna comment a lot on what Adrian was alluding to on the, on the tail end of what he was saying is the, you know, the market has shifted dramatically as COVID kind of took its toll, so to speak on a lot of the home health agencies the smaller mom and pops couldn't get, didn't have access to the PPE as effectively as the larger players. That was a big key portion of it. Staffing was a key portion of that. And, and, you know, looking at the margin, it's hard to maintain operations consistently when you're dealing with those two. So what we started seeing was considerable consolidation across the industry. So and it is still one of the most fragmented industries across the us home health cost of E entry is very inexpensive. 

Dr. Joseph Jasser (00:30:23): 

So you see a lot of these mom and pops come up. But consolidation is something that has been actively happening, but the, since COVID I mean, intensified rapidly I mean, and I think they, the icing on the cake of that is Iman's acquisition of kindred finalizing that that overall acquisition. And to your point, Adrian, in regards to the you know, multiple verticals you know, Laura's not alone in the you know, having hospice home health and PCs to gather stitched under a single umbrella. You take a look at the metastas of the world. You look, the accent cares, they're all doing the exact same. A you know, the, the key play here is what I'm seeing is market density. So they're identifying the markets that they want to go into and doing the, the strategic acquisitions and, or mergers to to build up that market density in the area. 

Dr. Joseph Jasser (00:31:18): 

So that way they got not only horizontal integration, but they got vertical integration across their products which really helps you know, the, the other thing that I'm seeing move very hard and fast is the movement to value based care to your point, Adrian, mm-hmm <affirmative> where I don't see it happening is the ma plans finding value in home health ma you know, the ma plans are struggling finding that the value you, the way Humana sees it with kindred. I think a lot of it is because home health is a commodity. It's a it's the, it's the, the, it's the easier point of entry for healthcare when it comes to pricing, but what they aren't seeing is what CMS is pushing towards here in the us is the home health value based purchasing they're resurrecting. 

Dr. Joseph Jasser (00:32:05): 

The from 2019 they're bringing or 2018 is when it went in 2019 is when it died, bringing it back for 2022. So essentially leveling the playing field for value-based care across the entire home health agencies. You know, you gotta upside in a downside to it. So either they're gonna be able either, either home healthcare companies are gonna build their tool sets effectively to be able to manage this new world order where I think we're gonna continue to see more and more of this mergers and acquisitions growth kind of move forward as we go to 2022. Interesting thing will be, what's gonna happen in my mind is what's gonna happen with telemedicine and to your point, Jeff, and that's why CMS here in the states made the position is you can visit somebody, but you can't give them a bath. 

Dr. Joseph Jasser (00:32:50): 

And home health is a personal touch in-home service. But I think we're leaving a lot of money on the table, so to speak by not expanding the service set that home health can do integrating home health with PCs is an example where I think there's great opportunity integrating home health with the ability to do a higher level of care. So, so we can take telemedicine into the home on a lighter touch process. So I think there's is gonna be some evolution around some of that as we go into 22 and 23 as we start to to see how telemedicine fits into this new world ecosystem, that the challenges prior to now were people didn't take up telemedicine because of the uncertainty and the personal connection and that sort of stuff. Well, didn't have a choice with COVID. And I think, you know, moving somebody quickly down the path is one way to one way to to, to, to get adoption. And that's exactly what happened. So I think we're gonna start seeing the evolution of that expand. And I with home health in particular, the combination of the three service lines with telemedicine is gonna be is gonna be a lot of I think a lot of value added to the overall clinical 

Adrian Schauer (00:34:04): 

Ecosystem. Yeah. And, you know, Dr. Joe, you were asking before how, you know, the single payer reality in Canada and Australia led to different reactions through COVID. One of the interesting things is, you know, reimbursement becomes reality in healthcare, right? As we all know, and one of the interesting things is any single payer market in a way is ultimately capitated right now. Does, does that mean all the actors have their incentives aligned in that action? No, not necessarily, but in the us, you have this historic difference between skilled meaning episodic care, right. And long term care, being more synonymous with personal care. And of course from a clinical point of view, that's not, that's not the right model. And so what we see in jurisdictions where you don't have that historic difference is you know, what is the right mix of services to support this this citizen. 

Adrian Schauer (00:35:18): 

I'm not gonna say patient right to support this citizen at home, through their their care journey. And it is some mix of, you know, personal care, nursing and therapy over time, not prescribed, not chunked into 60 day episodes, but you know, based on what I'm seeing of the patient in their home, what's the right intervention now to move 'em along their their care pathway. And so the absence of those silos I can tell you from, from experience across these markets gives a lot of degrees of freedom in what type of care we deliver. And then also how tools like telehealth and remote monitoring can be a part of the the care next. 

Dr. Joseph Jasser (00:36:06): 

You know, that last comment, Adrian triggered something in my mind and where I struggle in home health is that specific piece. It's a scripted service. It has to fit in a specific box and it has to meet X, Y, and Z criteria. And the clinician has to do a, B and C every time. Yeah. If we would stop thinking like that as a clinical clinical society and say the patient to your point, the patient needs services, what those services look like across the continuum will like, but doesn't necessarily mean we have to chunk it into episodes and do this now and this later. Whereas if we would layer these and say, okay, let's take the care of the patient as the priority and, you know, parse the care according to their needs. I think we'd have completely different outcomes. And I think that the overall is gonna be much better for the patient, but most importantly, I think we would take cost out of the system. 

Dr. Joseph Jasser (00:37:04): 

You know, when you take a look at we're giving everybody an apple pie, when they may not want the entire pie, they just want a slice. Yeah. Well, they're gonna get the whole thing, whether they like it or not. And then we can't change that. And the incentives to your point are not aligned for home health. Either we meet all the criteria to get an episodic payment and make money, or we get paired back to a per visit and we're underwater. So the incentives are almost misaligned to, to kind of take us down a continuum and kind of keep us boxed it boxed in that's. You know, when I start to think about the future of how value-based care may come into play, that's where I think human is thinking and how they're looking to evolve the way that they're delivering care into the home to these members. 

Adrian Schauer (00:37:47): 

Yeah. I'm not sure if you're familiar with the Bezo model, right? The model of community nursing, where, you know, essentially you structure your care into pods, you know, nursing led pods, but where you have also, you know access to to personal care services and you really download the decision making as close to the, to the patient as possible, right. And you give autonomy to these these nursing, right. It's originally a Dutch model that's been spreading around the world. And in my view, having seen lots of models of how care can be organized and delivered. That's getting pretty close to optimal, at least for elder care. Right. Okay. If I get a, you know, a hip surgery and I'm 40, that's maybe a different story, but for elder care, that seems to be a beautiful model, if you can sort it out. 

Adrian Schauer (00:38:49): 

And the other thing that this helps with, I'm sure we're gonna get into this topic soon is from a a labor market point of view and the meaning of my work and how fulfilled I am as an in-home caregiver. Birds org gets you to the community, not only a community with your clients, but a community with the rest of the care team that's servicing the, and I think there's a real magic if you can align. I mean, it's the caring profession at the end of the day, right? If you can empower and align people to work in a community that's, there's really magic there. And then the question is, okay, how do you roll that out through a health system, as complex as, as the us, you know, I don't have those answers, but I know there is some I've seen that there is some magic there. If you can really just get accountability into small pods and into a community 

Dr. Joseph Jasser (00:39:48): 

You M about you, you bring forward a very good point, and I didn't know what we were doing back then. This was back in my Cigna days of 2000, we implemented the pod. We used to call it physicians on demand. It was kind of a, a funny acronym, but exact same concept. What we discovered is patient populations don't traverse far from their central core. So we had the hub spoke with the clinics around it. Everything was cared for, for that member within that pod. And everybody shared responsibility and accountability for the outcomes and the results of that population within that pod remove the barriers of physician communication and moving work downstream to the nurses appropriately and the patient satisfaction and the overall to your point that the caregiver satisfaction was sky high. It was, you know, we didn't know it back then, but you know, it is a very effective model clinically speaking. It can be implemented now, not to the level that you're alluding to from a nursing care perspective, but from a population health perspective, it is very effective that I can point 

Adrian Schauer (00:40:51): 

To the other really interesting model. We see you know, internationally, when you look at us earlier a few years ago, they moved all publicly funding for you know, elder care in the home to a client directed model. But but more expansive than you'd see in some of the CDAP P programs under Medicaid. Literally, you know, I'm over 65 in Australia. I can get assessed by the public system, get a, you know, be a level two package. Great. That gives me 30 K a year to spend on home care services, Brit large, right. I then go find a provider who I wanna work with on this budget. And so they're competing to, for my business now that I have my package with that provider, the mix of services can go from personal care to nursing, to, you know, what, if, if I, I have C O P D I mean, maybe eat the best 60 bucks you can spend on or best 120 bucks as a new air conditioner that's in scope. So it's a, it's a very different model. And because the value, the, the dollars follow the patient, and you give 'em some agency in the process, but matched with the oversight of these certified agencies. There's another bit of magic there, right? How you combine patient choice with you know, a responsible clinical oversight model. 

Dr. Joseph Jasser (00:42:20): 

That's really intriguing. And I have so many comments to make, and so many questions are on it counter cause what, what immediately went to my mind on this when Adrian is that completely turns the table in regards to the around compensation. Yeah. Because to your point, the money follows the patient as opposed the money follows the clinician's decision. Correct. And in my mind, if patient, if companies are competing for that $30,000 to get your business, they can slay service on top of service on top of service, as opposed to what we have here in the us is you get a chunk of change to do X, as long as you do X, you're good, how much money you make doing it is up to you doing that, but there's no incentive to add Y and Z to that equation because monetarily, I get no incentive to do so. Yeah. It turns the table completely. And my mind is going crazy on ma works and all that sort of stuff is because of that exact concept. Mm-Hmm, <affirmative> give them money to a, to the private entity. And in this case, being the patient and watch what happens with the competition of getting services in their hands. Yeah. I, I, that's awesome. From a healthcare perspective, it would seem to 

Jeff Howell (00:43:30): 

Me like it's a very popular model in, in America as well that you have the control to spend your wallet as you, as you see, 

Dr. Joseph Jasser (00:43:39): 

Except in healthcare. Yeah. 

Adrian Schauer (00:43:41): 

<Laugh> 

Dr. Joseph Jasser (00:43:42): 

Healthcare. Healthcare is the one that's dragging behind all it now ma they have that opportunity. But once again, they're catering the product based on the revenue that they're getting from CMS, but then also the different type of services and, or healthcare healthcare insurance product that they have to have in a specific market to get the membership. Not the same, you know, if you really look at it, what we're trying to do in the us is move it from where we are now to a consumerism type of model, which is exactly what Adrian is alluding to. I wish we would get here sooner. 

Jeff Howell (00:44:17): 

And Adrian, I'm curious if you have any knowledge on how that's going. I know the program's been in place since at least 2017 when I first found out about it, I would presume that fraud is, is lower just because it's a more simple system of you qualify for package two, here's your $30,000 check go have fun. My question is when you empower people to spend their money on their own health, are they really, I know you said that there's a degree of oversight, but I'm curious if if it leads to people not making the right personal choices but they're happy anyways, because they're, they're the ones that get to make those choices. 

Adrian Schauer (00:45:00): 

Yeah. I mean, there's the you know, you hear a lot of chatter, at least when the program was being rolled out, it's like, oh, okay. This, you know, CHF patients just gonna order a flat screen TV with their home care package. And, you know, that's why, you know, you need the paternalistic you know, kind of top down. We know what's better for you better than, you know, what's best for you. Yeah. in its actual implementation the, so the program is popular. It's not without its problems. You know, there is a, a backlog of packages that are like, there's a waiting list for your home care packages, right. This is the flip side of you know, a, a single payer is one way or another care ends up being rationed. Right. so, so that's not perfect. 

Adrian Schauer (00:45:55): 

There was a, a Royal commission report. So, you know, basically think of that as like an auditor General's report on the industry. And you know, what came back, wasn't wasn't flawless and they're making some tweaks to the program. For example, the, the package used to go to the provider, right then the end of every month, they'd send out a statement, but the, if you underspend your package, that money used to sit with a provider, which created a strange set of incentives. So now they've just rolled that back right now. It's basically become more like an authorization, right? You where it's, it's postpaid for the services, but capped at what you have in your package. So there are tweaks around the edge around the edges that are happening. But for me, it is it's a very successful program. 

Adrian Schauer (00:46:49): 

I know various provinces in Canada are looking at it and whenever I have an opportunity to have an opinion on it I'm, I'm very bullish on that. I think the other interesting thing by the way, is that care management can be a billable service in the package. And if you look at what some people, you know, really need at that stage of life is like, you act, actually need a proactive, you know, health system navigator for you, because it's not just home care, you're gonna need to know how to interface with the rest rest of the health system. So tho those degrees of freedom to me are just net good. And you know, again, like speaking to the us ethos trusting the individual to make the right decisions with, with their funds, you know, whether they're public or, you know, the funds got there tends to have some good to it. <Laugh>, let's put <laugh> 

Jeff Howell (00:47:53): 

Dr. Joe let's switch gears. Let me ask you what do you think is something in home health that is maybe a, a fairly common narrative or widely agreed agreed to, and it's something that you may not quite agree with? 

Dr. Joseph Jasser (00:48:10): 

That's a tough one. Home health, I, I would say home one of the biggest ones that I hear more often and not is, and I'm coming from the Humana side of the table. Home health does not provide value and, or does not remove or improve outcomes. I struggle with that comment quite a bit knowing the population and knowing the aging population we have in the us and the inability for patient to see their clinician in a timely manner and the ability the clinician to give them enough of their time to manage their condition well, both in the office and at home is a challenge at best. The, the, the, the ethos here in the us is very focused on brick and mortar. Go see your doctor, and, you know, I'm gonna tell you what to do, and this is exact what you need to do, and you're gonna go home and do it get discharged from the hospital. 

Dr. Joseph Jasser (00:49:14): 

Same exact thing happens. What we fail as clinicians is that we assume that everybody understands what we're telling them. We assume they understand how and what they need to do, and we assume that they automatically are gonna do it. Unfortunately that is not the case. And I can pretty much say throughout my career, it's been the been the norm. They, they don't have the level of understanding to, to help them navigate the everything by taking the care to them in their home. We provide them the ability, one, the comfort, and then also the, to ask questions in a safe environment. And then also for us as clinicians to see things that we could never see before, do they have food in their fridge? Do they have carpets that are gonna cause 'em the trip? Do they have air conditioning? 

Dr. Joseph Jasser (00:50:06): 

Like, you know, Adrian was saying, these are all impacts. And if you take a look at it, 60 to percent of the overall downstream expenses are due to social components. So I don't care if you provide the absolute best care you can in the office or in the hospital, as soon as they go into their home, it can, it can easily fall apart. And we're missing. The biggest opportunity is to manage those patients in the home. And I think the other component of it is the, the lack of our ability to follow patients longitudinally in the home is the other area, you know, everybody back to where we were talking about the episodic components of it, mm-hmm, <affirmative> the longer we maintain connection and engagement with the patients, the better the outcomes tend to be. I, you know, and I'll give a point to an example specifically around transition to care. 

Dr. Joseph Jasser (00:50:59): 

Patients getting discharged from the hospital have a high propensity of readmissions unless they eat, unless they get a home health visit. And it can be either one visit with a medication reconciliation, or it can be several light touch visits over a co course of a couple weeks. It bends to cost curve dramatically with with readmissions downstream. We're missing that component of it. And I hear that a lot in the home health area. My answer to that is we should be looking at how to expand services in the home, get out of the box mindset and change the, the, the, the paradigm from we only prescribe X to, we want to care for you in your home, whatever that may look like. That's kind of the, you know, as, as I think about some of the, the, the things that I hear and, and, and don't agree with, that's where I kind of focus my thinking around is, you know, the, the, the things that we're missing in the home because clinicians, I hate to tell you, we've got our head buried into sand when it came, came to the home up until recently. 

Dr. Joseph Jasser (00:51:58): 

And COVID accelerated a lot of that thinking 

Adrian Schauer (00:52:05): 

You know, if I were to tack on one of the misconceptions let's say, in the, the general industry nav narrative and home care I'll pick a slightly controversial one, right? The anyone who's in this industry right now would describe it as a supply constrained, not to demand constrained market, right? Like <affirmative> caregiver shortages are absolutely at the top of the list of every provider everywhere in the world that we do business with. And there are very real reasons for that. You know, I don't want to downplay all the the very valid concerns, you know, whether it's pay or you know, quality of work or, you know, there's all sorts of things that make this a make it a tough profession. And there are just net net kind of shortage of caregivers. 

Adrian Schauer (00:53:00): 

But what I think is largely missing here is if you were to really look at the aggregate demand and the aggregate supply, and if you could efficiently put that together you'd be much better off than what we're seeing in the industry. So my point of view on this is, and, and let me start with, with an illustration of this you know, this is an industry with 60, 70% annual churn of caregivers. And when you interview the median caregiver on the way out of the home care agency they're working for, and you say, okay, why did you leave the number one reason you get is I didn't get enough hours. I didn't get consistent hours. I didn't get that, meet my preferences. And so, you know, why is this well, you know, imperfect scheduling of the, the, you know, the clients and the the caregivers I have within my agency, but even more than that is the fact that the, the agency is an official contract construct, separating, supply, and demand. 

Adrian Schauer (00:54:09): 

Okay. And so you might have, you had a bird's eye view of Toronto, you know, which for the most part, we do something like 80% of the care home care delivered in Toronto happens on our platform. If you look at that, I mean, you'll see a Beshore care worker coming in and out of a home in north York, you know, 10 minutes before a St. Elizabeth caregiver comes in and out of a home two doors down. And so what we're really focused on now kind of getting to to where we see the industry going. But one of the things that I think is hypercritical for the industry, or right now is to develop models where we can share that load better between agencies. And so our take on that is a lie market. So we do two things first schedule optimization tools to make sure you're doing the best fits you can with the staff you currently have, but then it's that 10 to 20% where it's really hard. 

Adrian Schauer (00:55:08): 

You know, you spend 80% of your coordinator time filling that last 10% of visits. And our notion is, well, if you could post that, that case or that visit up to a marketplace, and that could get picked up by a, a neighboring agency and you can have similar kind of quality controls would if it was your own caregiver going into the home ultimately you're gonna have be able to create the perfect schedule more often for for the care worker. And that's gonna create capacity in the system, less travel time, you know, the ability to say, okay, I'm gonna move a big chunk of my caregiving population to guaranteed hours or full-time employment, because I know if I can't fill a hundred percent of that that capacity myself in a given week, well, I could pick up a shift from the marketplace and you know, make sure I fill that schedule. 

Adrian Schauer (00:56:03): 

I think if we do that successfully as a, as a technology provider, but so as an industry, we're gonna drive down caregiver term, it's gonna become a more stable profession. It's gonna become you know, lower travel time, higher FaceTime kind of profession. And so that's one thing we're really focused on. And I think people who generally are in their kind of silos of my agency, my clients, my employees you know, if we can take a step back and find a model for sharing I think we'll be much better as an industry. 

Dr. Joseph Jasser (00:56:38): 

I, I, I, I, if I could do cartwheels here on, on audio, I will, because that's actually really, really, really smart on trying to crack them nut in a different perspective, to your point, you know, these agencies are turning down 40, 50% of their business sometimes because of staffing issues. Yeah. Now that also alludes to one of the bigger challenges of what we're gonna start seeing as home care expands and having come from the signifies of the world that crack the not on logistics, mm-hmm, <affirmative> of making sure that doc doesn't do left turn, so to speak. Yeah. And, and, and being able to route them effectively to hit eight patients in a day is not easy. Yeah. And you know that once again, what we're up against is as you decentralize care, you increase the, the draw time, windshield time, whatever you wanna call it, and the impact on the ability to see more patients yeah. 

Dr. Joseph Jasser (00:57:30): 

That they don't go hand in hand. And I think we're gonna start seeing that more and more so as the hospital at home kind of takes traction and some of them home, more larger moves to, to bringing care into the home evolve congregate setting in the us was done for, for the sole purpose of making staffing effective. I can take care of 10 patients, 15 patients in a, in a couple hours by doing rounds in a, in a hospital. Yeah. It'll take me three or four days to do so in in the community, even in the best case scenario, unless we leverage a pool of resources or unless we leverage technology differently than we do so right now. Yeah. those are things that I think are gonna really be an impactful be, I should say, are gonna be extremely impactful to the evolution of where we're headed. Mm-Hmm <affirmative> not only for home care, but as care in the home, so to speak evolves. Yeah. 

Adrian Schauer (00:58:24): 

And my, just, just to build on that for a second, you know, I'm gonna talk more about the personal care side of the world, but I think you have a cohort of aids that wanna work in a gig economy format and want that to be as friction free as possible. And you've got a cohort that wants stable hours, and I think to succeed, you have to try and have be excellent at both and have a model for both and offer that those two models have them work well together. And it is no easy feat, but on the, on the flip side, the technology tools at your disposal as a, you know, home care agency owner now are 10 X, what they were 10 years ago. So I think the industry's really ready to, to take this challenge on 

Jeff Howell (00:59:14): 

The, the and when caregivers exit, when they say they haven't gotten enough hours another popular answer is the pay, but the pay was really tied to how many hours they got, cuz they knew what they were signing up for on an hourly basis. And Adrian, as you talk about the schedule optimization, I see the, it almost brings it back to a Burer model geographically, where you might have a main caregiver and a main agency that you work with, but then you have these other caregivers that are close to you geographically that are picking up these gig shifts that you know, in, in most cases it's better that than, than the, the visit going unfilled. 

Adrian Schauer (00:59:55): 

Yeah. Yep. There's some, there's absolutely something to that. 

Jeff Howell (00:59:58): 

Yeah. Well guys, we're almost bumping up again. Start time here. I'll get you out of here on one last question. I'll start with you, Dr. Joe, give us a reason to be optimistic about the future of home health. 

Dr. Joseph Jasser (01:00:11): 

I, to me, it's, this is where care is going. It's been evolving since I first started healthcare. When I, when I finished medical school in 98 and I've seen it evolve over the course of my career. We were over 20 plus years. And every step as I've taken has gotten closer and closer to the home. I'll, I'll take back to one conversation. We had with clay Christensen back when I was at Humana who showed the evolution of it and technology from the mainframes down to the cell phone in our hands and laid that up in against healthcare. Yeah. Starting with the large institutions, moving to the to the free standing clinics. And then now in the home, the, the, his, his comment to the entire executive team at Humana was care is going to the home. It's the last evolutionary step. You can choose to ignore it or you choose to be a champion of it. I've chosen to be a champion of it. I think it's probably, to me is most exciting part of my career is watching this transition and being a part of the evolution. So that's, that's what gets me up every day. 

Adrian Schauer (01:01:18): 

Yeah. From my point of view it's an industry still with a ton of potential. So, you know, if you contrast our business, versus if I'm trying to help a merchant be better at e-commerce, I mean, there, you gotta be right at the edge of technology, right? You have Amazon's push the envelope, Shopify pushing the you're right at the edge of the capabilities of tools and software and user experience and so on. And home care. We're not at the edge. We have a, we just using the tools at our disposal today. There's a, you know, two X, three X improvement in efficiency that can be had, right. It's not to say it's easy. It's a, you know, our industry is a bit of a laggard for a reason. There's a ton of complexity. They're disrupted value chains and all sorts of things. It's not easy, but the capacity for improvement I think is vast. Because you know, we're still in catchup mode honestly, versus some of the more forward areas of the economy. So I'm super super optimistic at least of our role and what we can bring to the industry. 

Jeff Howell (01:02:38): 

Agreed. Well, I'm certainly doing as Joe, it's a mental Cartwheel right now. You guys really brought a lot of value to this episode. And I wanna thank you both for being here today and hopefully we'll catch up sometime soon at a home health conference and have a beer and be in, in real life. <Laugh> 

Adrian Schauer (01:02:58): 

Sounds great. That's great. Thanks Jeff. Okay. Thanks guys, Joe, take care. Bye. 

Speaker 4 (01:03:05): 

Home health 360 is presented by AlayaCare. First off. I want to thank our amazing guests and listeners to get more episodes. You can go to Alayacare.com/homehealth360 that's spelled home health 360, or search home health 360 on any of your favorite podcasting platforms. The easiest way to stay up to date on our new shows is to subscribe on apple podcasts, Spotify, or wherever you get your podcasts. We also have a newsletter you can sign up for on alayacare.com/homehealth360 to get alerts for new shows and more valuable content from AlayaCare right into your inbox. Thanks for listening. And we'll see you next time.