HHCN Franchise Forum: The Future of Home Care

This article is sponsored by Home Care for the 21st Century. This article is based on a Home Health Care News virtual discussion with John Dapello, CEO of Home Care for the 21st Century, and Lori McCauley, Vice President of Franchise Development at Home Care for the 21st Century. The discussion took place virtually on December 8, 2022 during the HHCN Franchise Forum. The article below has been edited for length and clarity.

Home Health Care News: I would like to start just by learning more about each of you and about your organization. John, tell us about your background and why you started Home Care for the 21st Century?

John Dapello: I was very blessed beginning from a very early age to be involved in home care, home health care, and hospice through my family. As time went on, having the opportunity to work with my mother in nursing homes without walls, very different from what we see today in home care. The whole process of going through and being directed through the government to introduce something that’s very different, and here we are today with Home Health Care. A lot of what was implemented back in the ’70s is part of what we’re doing today.

As we grew, and time went on, the interesting thing about where we are today is that we’ve helped open over 8,000 home health care and hospice agencies throughout the country. The opportunity that we perceived was such a blessing from God to be able to make a difference in that area and work with wonderful people in health care.

HHCN: Very nice. Lori, tell us a little bit about yourself and the path that led you to your role in Home Care for the 21st Century.

Lori McCauley: I started out actually in franchising in the med spa industry about 18 years ago. During that time, I was out in California and my dad had had a stroke. My mom was a retired nurse and she was taking care of my dad at home. We had private duty and home health at home, but they just weren’t providing the type of care that we needed. My mom was losing a lot of weight, and we had to put them into a skilled nursing facility.

I decided to move closer, they were in Wisconsin, so I relocated to Chicago. I saw this opportunity with BrightStar Care. I spoke to my mom about it, and I said, “I think I can really make a change in home care if I take this opportunity with BrightStar.” I had a really great mentor, Shelley Sun, and I worked with her for over about 10 years, ran her corporate locations, and then thought I was going to open up my own franchise.

Within about two years I went in at the agency level and was working with them and trying to figure out if that was the right opportunity for me, and each time it just wasn’t the right fit. I’ve always been looking for what is next in home care and I came across Home Care for the 21st Century. When I saw that they were offering a full continuum of care, I thought “This is it. This is where I need to be,” because most of the clients or patients that I was seeing in the home said– if they loved your agency they wanted you to do more, but then agencies are very segmented and you couldn’t do more. I thought this is where I need to be and I relocated to Florida to help launch the franchise and three and a half years later here I am.

HHCN: Very nice, awesome.Lori, how is health care changing in home care?

McCauley: I think something that’s super interesting is if you first take a look at the hospital sector, a hospital started out as a general practitioner and you had one physician that you saw, and you went and had a hospital stay and you had one invoice.

Today, if you go into the hospital, you’re seeing multiple hospitalists, multiple specialized physicians, and when you receive your invoice, you’re receiving multiple invoices. There’s one from the emergency room, there’s one for the anesthesiologist, there’s one for infectious disease, there’s one for the actual hospital stay. You’re actually having multiple businesses within one health care organization, but separate entities, which I think is interesting.

Where home care is the exact opposite, home care actually started out and still is today, to a high degree, very segmented. What I mean by that is the majority of the agencies only offer about one service. You have a lot of personal care agencies out there, non-medical, that are only offering non-medical care. You have Medicare Home Health that’s offering skilled services, and you have hospice companies. They’re all staying within their wheelhouse.

It’s only recently that you’re starting to see in the last two years a ton of acquisitions from large organizations, and they are trying to create a one-stop shop. That’s really the focus of Home Care for the 21st Century is taking that to the franchise world and making it a one-stop shop, where you have multiple organizations that you’re able to work under one umbrella with one invoice.

Then what we’re also seeing is an increase in urgent cares, outpatient surgery centers, and rehabs and you wonder why that’s important. Well, it actually changes the dynamic of care, because originally you’d always go to the hospital or the ER, and now that’s not the case. Now you’re going to urgent care, or you’re going to an outpatient surgery center. What does that mean?

That means that people are coming home quicker. They’re not staying in the hospital, they’re coming straight home, and so with that you have opportunities to help families out quicker, sooner. You’re also seeing outpatient rehabs, outpatient rehab rather than as many skilled nursing facilities that are going up. Outpatient rehab means that we’re discharging quicker. We’re actually going through the patient population a lot quicker than we used to a few years ago.

Then John was talking about his mom, the founder, Rosina, in the skilled nursing facility without walls. Well, now we’re hearing the term hospital without walls. You heard that a lot within the pandemic, and that’s just showing what the trend is going to be. How much can we push that envelope in order in what we’re going to do in the care in the home? We’re trying to create something more than we ever have in the past.

We are seeing a huge influx in Medicare Advantage Plans. A lot of people don’t understand how that affects them. A few years ago, the majority of families were on traditional Medicare, and almost every single skilled nursing facility, physician, and hospital takes traditional Medicare, but they do not necessarily take Medicare Advantage Plans. Now you have to find who is in my network, and it’s not always with the physician you want to work with, so you have to be more selective.

Overall, we’re seeing higher costs, higher cost to deliver care and lower reimbursement. What that’s really saying is that we are creating a ceiling on health care, because if you think about what it costs for private duty specifically, in the last 10 years it was about the same, $22 to $27 an hour. Then you paid your staff like $12 to $14 an hour. There are some markets right now where we’re seeing $40 to $45 an hour paying staff $20 to $25 an hour which you haven’t seen in the last 10 years.

We’re also seeing paper going to automation, while with automation comes subscription, and with subscription costs residual fees every single month. We’re just going to have to look at how we can work smarter, not harder.

Dapello: And have multiple revenue streams. I think that’s the key, Lori. We can’t just rely on one, we have to be able to service a patient regardless of their medical condition, in addition to that, whatever service they need in the home when it comes to medical orientated services, we have to be able to do it.

McCauley: Yes, you have to give yourself more opportunity within that segment.

Dapello: Yes.

HHCN: Absolutely. Lori, you already touched on this. I think that’s a good segue when you mentioned automation and just kind of the evolution of this industry, but tell me how is technology going to be a factor in the future of home care and how it relates to your company?

McCauley: Technology in general is definitely going to be a key role. We have a staffing shortage, and we can’t be everywhere, so we also need to reduce cost and be more efficient. We need to bridge the gap and work smarter, not harder. Our philosophy at Home Care for the 21st Century is creating smart health care. You hear about smart homes, smart technology, smartphones, and smartwatches. We’re taking that same segment and putting it into home care.

Currently, we are working with artificial intelligence and machine learning activity monitoring and wearables within the home. What that does is it creates an environment where we can detect change in behavior that actually will determine whether or not there’s a change in condition. An example of that would be, I’m sleeping longer than I typically do. I typically get up between 7:00 and 8:00, and now I get up at 9:30.

Usually the reason why you’re sleeping late is one, you might have had a rough night of sleep. You tossed and turned and didn’t sleep very well. You took a really long nap in the afternoon, and so you weren’t as tired, so you went to bed late. Or you’re not feeling well. If you’re not feeling well, you want to stay in bed longer. What we’re trying to do is identify the reasons why some of this activity is happening.

You can also think about, am I eating three meals a day? Am I taking too many naps in the afternoon? Am I actually doing my physical therapy rehab that I’m supposed to do when I am discharged from knee surgery or hip surgery? How often am I using the restroom? Is it too often? Is it too less? The key is not to have cameras in the home or to big brother them, but it is to actually create smart monitoring to make sure that we’re making good decisions and trying to prevent something bigger from happening.

It also can detect fall detection, so fall detection within 40 seconds which most of the wearables may not do because they look for fastballs. Right now I’m doing some research on smart clothing, which I think is very interesting. Smart clothing in regards to being able to tell whether or not not you have an incontinence issue. I would really see that we could use some smart briefs if we have nonverbal people who have dementia, those with autism, those with certain issues, that they might not be verbal, and we can actually help them without having to make it a disruptive situation. Overall, the goal really is to create a preventative medicine approach rather than reactive.

HHCN: How did the COVID-19 pandemic affect the future of the health care industry for your company? What have you seen just in general when you look back on the effects of that?

McCauley: The first thing since we were talking about technology, it really opened Pandora’s box to technology opportunities, because prior to that there wasn’t much talk about it except at the physician level. It almost nudged all of the insurance companies and the government to say, “Hey, we have to actually start looking at some other things,” where I don’t think they would’ve without the pandemic. I always say that if it’s reimbursable, it’s 10 years old. Right now there’s so many things that you’re talking about in technology that’s still not reimbursable, but it’s actually at least opened the door to the concept and to the idea to look at different things.

It’s also shifted everything into thinking that people are more concerned about being in a facility, and they really want to be at home. Now, that’s always been the case. If you’ve been in this industry you’re hearing that 90% of people want to stay in their home. It was commercialized so much more in the media. You were hearing all these stories and now the layperson even knows much more that people want to stay at home.

John, with our consulting division, we have seen the biggest influx in the number of agencies in the last two years. In 25 years of doing business, the last two years have been amazingly large in regards to people wanting to get into health care more than ever. At the same time, we have seen how it has affected the workforce, and I think that’s the toughest part.

We have this huge need coming, and you would think with the pandemic, “Oh, health care’s great,” but it actually created where the service industry has been really hit. It’s not just health care. It’s in retail, it’s in hospitality, it’s in travel. We are finding that people want to work remotely. They don’t want to work face-to-face or have to come to an office. We’re having an even harder time to find those for the workforce.

Then we have seen a huge influx in travel nursing. Now, travel nursing has been around for a long time, but in every one and two nurses that I meet right now, they have done travel nursing in the last five years. Travel nursing has been huge. They also are getting top dollar for that. With top dollar, it’s hard to recruit a DON, an assistant director of nursing, a field staff nurse to come and work in an agency, because nurses don’t want to turn down all of the opportunity in regards to the financial aspect that they’re getting rewarded for.

At the same time, we’re also seeing an influx of travel nurses who have been burnt out. They’ve been working in COVID, they’ve been traveling a lot, some were working six days a week. Now they’re interested in taking the money that they have earned, and they want to turn it into an agency or become their own owner. They want to be their own boss. We’re seeing more of an influx of health care providers, physical therapists, nurses, and nurse practitioners that are wanting to actually own their own agency. I think more than ever before wanting to leave some of the hospital settings. That’s a positive piece, but again, we really need to work on the staffing aspect.

This excerpt has been edited for length and clarity. To watch the full discussion on video, please visit:

Home Care for the 21st Century provides senior home care services and matches you with the perfect caregiver. To learn more, visit: https://www.homecareforthe21stcentury.com/.

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