Like all home health providers, Nizhoni Health has had to adapt on the fly to stay afloat amid the coronavirus emergency.
But with a patient population often living with highly complex mental illnesses, the Massachusetts-based home health provider has had to face very unique challenges as well. Leaning on a strong technology infrastructure has allowed Nizhoni Health to “not miss a beat,” according to founder and CEO Joe McDonough.
McDonough gave Home Health Care News an inside look into his company’s coronavirus response strategy and future plans during a recent episode of Disrupt. Subscribe to Disrupt via Apple Podcasts, Google Play Music, SoundCloud or your favorite podcast app.
Highlights of HHCN’s conversation with McDonough — recorded in April — are below, edited for length and clarity.
HHCN: For those who aren’t familiar with Nizhoni Health, can you go over your operating model?
McDonough: We’re a typical VNA. However, we specialize in patients who have behavioral health diagnoses, usually also with chronic medical comorbidities. It’s a different type of population. It’s a younger population that’s mostly homebound. A lot of our patients are also under the Medicaid program.
What does that “typical” patient look like in terms of age, illness and homebound status?
Our patients tend to be between the ages of 30 and 60. Again, it’s a much younger population than the traditional VNA regularly works with. Our patients tend to have been in the system a long time. They’re chronically, mentally ill.
It’s hard to say what a “typical patient” looks like, but I’ll give you an example of a patient who fits the profile. We might have a patient who has schizophrenia. They’re likely someone who has been diagnosed for the last 20 years. They are on a list of probably 12 or more medications. They also likely have concurrent medical issues. This person might be 45 years old, but I would figuratively add about 20 years on to that. They face some of the same physical challenges as a 65 year old. When we work with them, we certainly treat the mental-illness aspect in a psychiatric sense. But really, we look at a psychiatric diagnosis as a complicating factor for treating the medical issues.
Let’s say someone is diabetic, and they’re prescribed insulin twice a day. Well, a lot of our patients don’t have the cognitive ability to even operate the glucometer, nevermind trying to correlate their scores to what their dose of insulin should be and then administer it safely. So for that type of patient, we may go in twice a day and administer their insulin, assess their symptoms and assess all their systems. We work closely with the psychiatrists that they have as well as the primary care physicians they have.
Unfortunately, in a lot of cases, these patients exist in a very fragmented care system. Oftentimes, you don’t have the primary care provider and the psychiatrists speaking. Meanwhile, a lot of our patients are also under the Department of Mental Health. They may work with a vendor at the Department of Mental Health that assists them with their housing and psychiatric support, plus social determinants such as food, heating and that sort of thing. We work with everybody. Our nurses, physical therapists and occupational therapists really function as a hub of a very complex system.
What about size and scale? How large is Nizhoni Health?
We’re pretty much statewide in Massachusetts. We do about 21,000 patient visits a week. There’s certainly a lot to manage. We have over 3,000 patients and about 750 employees. The vast majority of our clinicians are employees.
You actually founded your company. Why? What need did you see in the market?
I went to graduate school at Yale University. While I was in graduate school, I worked at some home care programs down in Connecticut, specifically in the New Haven area. Connecticut, at that period of time, had a very well-developed psychiatric home care system. It was thriving. They were doing some very interesting things back in the mid-to-late 90s. In the year 2000, I got engaged to my wife. We decided to come back to Massachusetts, where I’m originally from. I decided at that point that I wanted to start a company. When I was looking at opportunities in Massachusetts, something surprised me.
Massachusetts has a very robust system for VNAs. They have tremendous VNAs that have been around for many years and do wonderful work. But one thing I noticed was that for patients who were chronically, mentally ill and who weren’t homebound, often the younger population, there weren’t a lot of agencies meeting those needs. Oftentimes, these patients would be discharged from a hospital with medical needs, but they weren’t able to access care. They were consistently going back into the emergency room, being hospitalized up to 20 or 25 times each year. So, that’s why I decided to start this company — to try to meet those needs. And we have done well over the years. Our patients are simply a population that continues to need more care. The need exists in Massachusetts, but certainly more is needed throughout the rest of the country, too.
How has the COVID-19 virus impacted your operations?
Well, we’ve been fortunate. Before all of this, we had spent the last 18 months focusing on our technology infrastructure. We’ve become cloud-based as a company. Our CIO, Dave Ledoux, has really pushed us. Sometimes, we resisted him. But he said there may come a time where you have to work remotely. And as we’re looking to expand across the country, at some point, we want to set up an infrastructure that allows our staff to work from anywhere.
When this crisis happened and businesses have had to work from home, we have not missed a beat. We’ve been able to run our revenue cycle remotely. We’ve been able to run all of our clinical operations remotely, run intake remotely while continuing to take patients. We’ve even actually done a virtual orientation with new employees. From those standpoints, we have not really been affected that much.
Now, as far as nurses and therapists going out into the community to visit our patients, we’ve mostly been able to maintain all of our 21,000 visits a week. But there have been small instances where patients were very worried about having people come into their homes — and they’ve refused care. I would say 99.9% of our visits have not been impacted.
Every health care entity in the country is struggling for personal protective equipment (PPE). That’s our biggest challenge at the moment.
Have you had to change how you source PPE? Or how you utilize it?
Oh, absolutely. We have gone through any type of channel. We actually just got a large shipment of facemasks from a company in Ireland. It’s been a huge cost-driver for us, as it has been for other agencies.
Has Nizhoni had COVID-19-positive patients?
Yeah. We have seven total. Five are in the hospital. Two are in the community. We haven’t seen the big surge in the community that everybody has been anticipating. But certainly, we’re in the midst of it right now. So who knows what happens in the next few weeks. We’re ready for it.
What challenges are you facing related to the unique population Nizhoni cares for?
It’s difficult. It’s hard to get a lot of our patients right now to their primary care appointments. A lot of that has stopped. There’s just a lot of challenges. Hospitals are really focusing on COVID-19 right now, so sometimes it is even difficult to get a patient into the hospital as well. The system is on pause right now.
Sounds like it’s calling a lot of audibles on a day-by-day basis.
Well, you have to improvise. MassHealth, which is the Massachusetts State agency that manages Medicaid, has been very helpful. They’ve been able to extend the time we have to get physician signatures, for example. They’ve been able to relax other regulations, too.
I’m sure there are a few, but what are the biggest lessons that you’ve learned so far?
I think everybody had to pay attention to their technology infrastructure. That can make or break you in a situation like this. The other important thing is to have a strong culture. You need to have a culture where people trust each other, where there is a lot of communication. Communication is just hugely important. As soon as we get information, we will analyze it, look at it, update our policies and procedures. Then we try to communicate that information to our staff as much as possible, as regularly as possible.
Then, again, you have to be able to improvise. You have to be nimble enough as an organization to adjust to crazy situations like this that are unanticipated.
You were very bullish on the future of Nizhoni Health and your growth plans for 2020 when we connected a few months ago. Are you still as optimistic about what the future has in store for your company?
Oh, absolutely. I think one thing this crisis has emphasized is how much our patients do depend on our care. It’s reinforced how much social determinants of health — all the different things we help with — matter. As we refine our model, we’ll continue to look for ways that we can create a better quality of life for our patients — and do it in a way where we can utilize data and technology to provide value and return on investment for our payer sources. I think there’s a huge need for our type of care nationwide.