How Best of Care Went From Family Business To A Home Care ‘Risk Taker’

At its core, Best of Care is a family business.

But that hasn’t stopped the Quincy, Massachusetts-based personal home care agency from thinking big and evolving.

Best of Care has over 400 home care aides, administrative staff, care managers, nurses and move managers. The company also has a care management division, TUCKed In Eldercare.

Earlier this year, the company acquired Moving Mentor Inc. — a move management, organizing and consulting company. The company has also purchased a few Assisted Living Locators franchise geographies.

When it comes to business moves like these ones, CEO Kevin Smith isn’t risk averse.

“We try to be something for everyone at our company,” he told Home Health Care News during his recent appearance on the Disrupt podcast.

During the conversation, Smith also touched on the importance of having a diverse payer mix, Best of Care’s adult day aspirations and its move into the hospital-at-home space.

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The below is edited for length and clarity.

HHCN: For the audience that may not know you, can you talk about your background and how you got to Best of Care in the first place?

Smith: I started with Best of Care in 2007, so I am just about to hit that 16-plus year mark. I started as a newly graduated person from college who, like many people, just really wasn’t sure what I was going to do.

My father started this company in 1981. I took a flyer on working with him and said, ‘You know what, this is sort of a big opportunity. I should probably try this, and maybe I can rule this out and move on to the next thing.’ Clearly, I’m still here. The journey was that I did literally every single job you could imagine at Best of Care, right out of the gate. I was hiring people, I was running payroll and I was going out and helping in the field during emergencies. I was driving home care aides to work during blizzards and inclement weather and making sure people got what they needed. I was doing emergency grocery shopping for clients. Then I slowly grew into a leadership role. I eventually became CEO in 2019. I’m an owner of the company as well. I’m a second generation family business owner. That is the journey from A to B.

I know that retention has been good recently at Best of Care, do you mind sharing any successes you’ve had there?

Ironically, thanks to COVID – and how limited we were with face-to-face and in-person stuff – we were really forced to figure out the best way to get people hired quickly in a way that we felt was safe, that we were comfortable with, that was appropriate.

We’ve taken that model and used it in what is called the post-COVID world as well. We can help hire new people expeditiously, and position them in front of our scheduling coordinators who handle all of our intakes and manage the schedules of all these employees. We’ve been able to get folks hired quickly, and then make sure that our schedulers understand the importance of getting work onto their schedules immediately. If you can really find a way to prioritize, and win the timing battle, you can get folks out to work very quickly.

We know that there’s work to be done, and people waiting for care. You can put new hires in the town, city or community where they want to be. You can really make an excellent first impression on that person, because you are putting your money where your mouth is. All of our job posts, all of our ads, say work close to home, make this much, starting pay of X, or a range. When you deliver on this, we find our employees are sharing that with friends, family, and their professional network. We have built what has turned into a successful employee referral system. This happened, simply, because we’ve done what we promised, hired people and got them out to work quickly.

We also talked about your Medicaid and private-pay mix. When you became CEO, I believe that you said you were 95% Medicaid and about 5% private pay. That’s now closer to 70%/30%. Take us through why you decided to get involved more in private pay?

With that 95/5 split, we can actually kind of go back to the early aughts there, maybe even early 2010s. At that point in time with the private pay versus Medicaid scenario, the rates were upside down, meaning private pay had outpaced some of these state Medicaid rates dramatically. That was really the impetus for me to say, ‘Why don’t we try to get a piece of this market share, where the margin is far more favorable for us, and then leverage that profit into hiring efforts?’

At the end of the day, anytime I’ve spoken, either as a guest on a podcast, or as a contributor, it seems like I’m always tying it back to the workforce, because as a provider it is a bit of a race to try and find as many quality people as you can.

We knew we could take that margin, reinvest in hiring, recruitment, retention strategies, and use that to expand ourselves both in size and also in scope and geography. In addition to the margin aspect of it, I also knew that I had seen some changes in the way that our Medicaid-based business was changing, in terms of things like training, education, compliance and audit.

You have to think ahead and know that anytime that you’re working with government-funded dollars, you’re going to be subjected to a really compliance-minded strategy, which is fine. That’s something that we’ve always been happy to comply with, and haven’t really faced many major challenges with. But when you know that there could be unexpected change, you have to be able to bank on something else. As cliche as it sounds, I knew that we needed to diversify our revenue streams.

Ironically, it’s private pay that’s been seeing a lot of pressure recently because bill rates have gotten really high, at least in certain parts of the country. Providers are thinking about getting into Medicaid, whereas you sort of went backwards in that process. Now, you have this healthy mix. Why are you bullish on Medicaid moving forward?

I wish I could take credit for that. I’m definitely the beneficiary of this legacy model that’s really all credit to my dad, Steve, who started this business in 1981. He obtained several contracts, over the years, with state funded home care entities, and grew it to a point where, when I came in, there was some history, some infrastructure and some really solid bones.

It is ironic, because we see so many companies now who start out as private-pay organizations. Who can blame them, right? If you think about the franchise networks, they are hyperlocal, they buy a certain territory, and they’re trying to find that private-pay business. Again, why wouldn’t you? That can be more lucrative. The rates are oftentimes more advantageous from a reimbursement standpoint, and you can negotiate and control them. You can do things like create minimums. The reason you’re seeing some of these people shift gears now is that maybe this thing has hit its cap, maybe there is finally a threshold.

Medicaid is a very logical place to look because from a demand standpoint, and from a volume standpoint, you’re dealing with this massive aging population whose needs are more and more acute. More and more states are recognizing the value in spending on home care, as opposed to nursing home and facility-based care.

It just so happens that my company went the other way around, where we already knew the Medicaid business, and so private pay felt like a very natural and logical extension for us to take.

Have you considered any other alternative models? For example, adult day or being a partner in hospital at home, or one of those other emerging models that we see centered in the home?

I’ll try anything. I’m something of a risk taker, as evidenced by the fact that we now have a care management business, a move management business, assisted living locators, placement services, private-pay home care, and traditional home care. We try to be something for everyone at our company.

We have yet to become involved in adult day. They’ve been on my radar, for sure.

That’s kind of settled science that adult day is an effective way for people to get out of their homes and interact with other people while getting the care that they need. I support it. I certainly think that a company like ours is well equipped to provide the human power behind locations. I do think that, at some point, folks in that adult day space may tire of the recruitment angle, because they’re no different than us where they are going to be looking for the best quality staff they can find to work in those communities. At some point, maybe some of them will say, ‘You know what, maybe we could shed a lot of expense and partner with Best of Care, or insert home care name here.’

We were selected to participate in a hospital-to-home partnership program in Massachusetts, here with one of our state-funded contract partners — Beth Israel Deaconess Hospital- Plymouth. We are going to be the in-home care provider, whereby people who go to the hospital through this grant funding may be eligible for home care, immediately upon discharge, care provided by us.

We are also going to provide a care management piece to communicate the progress, any challenges, or any issues or concerns back to the social work team at the hospital to make sure that we’re following and appropriately documenting and supporting this transition with some wraparound services. The hope is that by providing this kind of expedited authorization of home care for folks coming home from the hospital, we can alleviate some of those familiar faces in the ER. This is clearly going to be a system in which we can track the outcomes and the successes very easily. Hopefully we can use it to justify that this is a winning model.

We hope to hear more about when this might start, but it could be starting as early as this fall. It’s something that we’re excited about. We’re going to identify a team of caregivers who will be our, task force. They’ll be given a stipend in order to participate on this team. They will be incentivized from the pay rate standpoint.

What’s the unique take or opinion that you have about home care’s present or future?

In the next three to five years, home care will have escaped — through lots of hard work, lots of noise, lots of advocacy — this minimum wage, kind of underappreciated lowly-paid designation that accompanies it in every piece ever written.

I can speak through my own local lens here, and say that I’d be hard pressed to find a company who is starting home health aides or home care aides at minimum wage in Massachusetts. The job is not worth minimum wage, no matter where you are. The drumbeats have been rising steadily. With enough people aging together, who are desperate for help, something will flip.

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