Bill Thomas: Home Care Providers Need to Get into the Real Estate Game

As the home care industry continues to seek out ways to evolve and deliver better care to older adults, providers may soon find themselves operating in a largely untapped arena — real estate.

That’s according to senior care expert Bill Thomas, one of the masterminds behind the Green House model of smaller senior living properties and the founder of global nonprofit The Eden Alternative. In addition to those roles, Thomas is also the founder of Minka, a company that makes 3D-printed tiny homes and communities.

Home Health Care News recently caught up with Thomas to discuss industry trends, why he considers home care providers “the new sheriff in town” and emerging Medicare Advantage (MA) opportunities.


“Medicare Advantage, to my surprise, is turning out to be the most powerful tool for change in the whole field of health care — and for older people — that I’ve seen in my career,” he told HHCN.

Below are other highlights from HHCN’s conversation with Thomas, edited for length and clarity. Among his previously mentioned roles, Thomas also serves as medical director for Lifesprk, a Minnesota-based home-based care provider.

HHCN: In the past, senior housing has dominated the conversation when it comes to aging. Can you talk to me about the rise of home-based care?

Thomas: We’re increasingly understanding that it’s better for people, better for families, better for the health care system, better outcomes and better for controlling costs if people can get the support they need in their own home rather than having to leave.


I am a fervent advocate of expanding and strengthening our country’s network of home care services.

We recently had you at our sister site’s event — BUILD — in Chicago. During a presentation, you talked about how home care agencies are “the new sheriff” of post-acute care. What did you mean by that?

My background is as a physician, so all of my education and training was oriented around the hospital. If you spent the day in a clinic, that was kind of weird. “What are you doing in the clinic? Everybody knows that the hospital is the center of the health care universe.” We used to see the hospital as the sun — and other kinds of care as planets circling around the sun. We’re moving away from that to seeing the hospital as just one node in the network.

Hospitals are good for some things — and terrible for other things. Home care is good for some things — and terrible for, say, brain surgery. Do not get brain surgery at home! Just going on the record on that.

Different parts of the system do different things well, but the monopoly that hospitals have had in terms of controlling resources, controlling clinical treatment, controlling technology, that monopoly has been broken.

More and more, the people who are responsible for writing the checks that pay for health care, whether it’s the government or private insurers, increasingly realize that a more balanced approach to the kinds of services that they pay for can yield better outcomes. That’s what I was getting at when I said the new sheriff in town.

Between Minka, the Green House Project, Lifesprk and all your other projects, you’re a busy man. What else are you up to these days?

At Minka, we are dedicated to creating a new kind of housing. It’s what we call independence-oriented housing: compact houses that help people live where they want and how they want.

We see housing as a very important part of the equation going forward. We think that people need housing that serves them better than classic single-family suburban houses, which are made for raising families — not getting old. I’m spending time working with our Minka team to help us grow our company and be successful. The Minka houses we’re creating are really meant to be plugged into sophisticated approaches to home care, so that we’re able to actually optimize the housing and care in a way that can help people stay out of the hospital, out of the nursing home, out of assisted living and live the life they want to live.

This is where my relationship with Lifesprk comes in.

The reason I’m working with Lifesprk is that they’re one of the only companies that’s combining whole person care with population health. If you look at a lot of the action with population-based health contracts, most of the companies are slicing off the most complicated patients and doing intensive disease management. I think that’s fine. It’s great if you’ve got COPD and you get a great team that’s helping you manage your illness.

What Lifesprk is doing is different in that, instead of just taking the most acute patients and managing them very aggressively, Lifesprk is oriented around the idea that if you can help lots of people make decisions about what matters in their life and what they want to achieve … you can actually improve outcomes.

I think there is going to be two approaches to population health at home.

One is going to be a very small slice of the market: intensive management of very complicated patients. The other will be Lifesprk and companies that try to copy them, attempting to have an influence over the health and well-being of a large number of people, many of whom are living without serious chronic health conditions.

I recently wrote a story about how the lines between senior housing and home care are blurring: for example, a home care agency that also runs a community center where its clients can gather in a more social setting. Is that a trend you’re seeing more frequently?

I’m not seeing it frequently, but I think we are going to see it much more.

If you decide that you’re going to quit your job and build assisted living facilities, you’re going to design a building for a very specific kind of care. They go together — the building and the care are matched. What’s coming is a breakdown of this idea.

We’re going to be seeing a whole range of new combinations that are mix and match. We’re going to be creating architectures that enable people to live as comfortably as possible, and then organize the care around the person — not around the building.

A system that defines care in terms of the building is inferior to a system that defines care in terms of the person. In terms of home care, we will be seeing lots of options for people to stay in the house they love and be supported through a journey that takes them forward in time. And we’re going to be seeing new kinds of residential architecture.

I’m not shy about saying that I think Minka is one of the new solutions in this arena.  

What at-home care industry challenges are you seeing, and are there any creative solutions you like best?

I think anybody you talk to is going tell you pretty quickly that workforce issues are top of mind.

I always like to make the point that the workforce issue in home care is not actually a shortage of workers. Home care is a beautiful calling. It can be extremely rewarding, but it doesn’t pay as well as it should. What we’re really facing is a societal misjudgment where our culture pays too little for home care services.

For example, we’ve decided that a person working on a med-surge floor in a hospital is worth more than a person working with an elder in his or her home. Why is that person working with an elder at home worth less money than the person working with somebody in the hospitals? There’s no rational basis for that. If we can begin to value home care on par with acute care, then the workforce issue would get a lot better overnight.

What opportunities — or just shifts in home care business operations are you noticing? For instance, we’ve covered Medicare Advantage frequently, as well as how home care agencies are starting to become more specialized in focus.

I think it’s good that some home care agencies are specializing in particular areas of interest and skill. That’s a sign of the maturation of the field.

I think there are two pieces to home care that are currently in their infancy and are going to become incredibly important. The first is technology, and I want to highlight two companies I think are getting it right on technology. In order to meet the challenge going ahead, home care agencies have to become technologically more sophisticated than they’ve been in the past.

I think Honor is seeing some real success with its technology platform, and that we’re going to see more home care providers increasingly sorting themselves into technology platforms. The second company is GrandCare. They’ve got what I consider to be the most experience and the most robust platform for that kind of technology.

Now, if we can flip over to the housing side, the idea is there’s a giant mismatch in our culture between the housing we have and the housing that’s good to grow old in. We built millions of housing units with absolutely no thought to the needs of an aging population. And now we’ve got to fix that.

I think we’re going to see the rise of pocket neighborhoods, where home care providers are going to be able to support, say, half a dozen elders living in six smaller houses clustered around a little common area. Home care agencies are going to be able to start getting into the real estate game. It almost sounds weird. “Whoa, we’re home care. We don’t touch real estate. We just ring the doorbell and people let us in.”

In the past, I think that was almost entirely true. But in the future, home care providers are also going to be providing the home.

What do you think 2020 is going to bring on the Medicare Advantage front?

I actually think of Medicare Advantage as a giant hammer.

It is increasingly making the radical proposition that what matters most is the health and well-being of the people who are insured. MA has so far maintained a focus on what we call the “triple aim”: better outcomes, lower costs and better satisfaction.

We in the field have very little experience with insurers that are organized around those priorities.

We’re much more accustomed to insurers who want to push down on reimbursement and offer you less money for the same service, regardless of what happens to outcomes and access. Medicare Advantage, to my surprise, is turning out to be the most powerful tool for change in the whole field of health care — and for older people — that I’ve seen in my career.

We are seeing ride-hailing companies like Lyft and Uber dip their toes in the home care industry — partly to help address social determinants of health. Are these kinds of partnerships with home care providers the future?

There’s a great example of technology platforms beginning to see the incredible size and value of this market, and wanting to do business in our space.

I think we’re going to see some of these companies wanting to come to the table with us, and talk with us about how they can provide value to elders and their families.

Here’s the thing that I think we need to keep in mind: All of these companies you talked about, they are all aging illiterate.

These companies emerged in a way that was completely separate and apart from the reality of aging in America. When they sit down at the table with us, we are sitting across from smart people with some great offerings who don’t know anything about aging. It’s going to be important that we take the time and ensure that what they’re offering — and what gets delivered to elders — is appropriate and not just an afterthought.

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