Why Middle Management Is So Critical To Home-Based Care Providers’ Success

When dissecting what makes a successful provider in home-based care, the spotlight often gravitates towards the C-suite level, or to the caregivers or home health aides on the ground.

That’s generally for good reason.

However, lost in the shuffle at times are the middle managers who are consistently leaned on to execute a CEO’s vision and create a winning and sustainable culture.


“We spend a lot of time, as an industry, talking about the direct care workforce and the CEOs, but there is this middle tier of folks that don’t get a lot of attention,” Darby Anderson, chief government officer at Addus HomeCare (Nasdaq: ADUS), told Home Health Care News. “Yet, they are critical pieces to the successful delivery of home care services.”

The Frisco, Texas-based Addus currently provides home-based care services to about 47,500 individuals through 203 locations across 22 states.

The role of middle management

Middle management positions include clinical managers who ensure compliance while training staff on medical procedures. They also include, for instance, client services managers who act as a point of contact for clients and coordinate care plans.


Those managers — all the way from the clinical side to the financial team — play a critical role in an agency’s operational success.

A recent analysis from McKinsey & Co. found that strong middle leadership is linked to improved financial performance and talent development.

“They’re the local business leaders,” Anderson said. “They are driving business development. They’re maintaining local-level referral sources. It’s their job to instill those cultures, beliefs, new programs and initiatives, while also problem solving.”

Business hierarchies are different at every company. A middle manager can mean several different things.

One of the most difficult positions in that area at Addus is a service coordinator, Anderson said.

“A lot of agencies call them supervisors,” Anderson said. “These are the folks that have to do the aide hiring, onboarding, training, scheduling and payroll processing. They are the customer service line to the referring case managers. They handle the problems with consumers, problems with families, problems with aides and all that kind of stuff. That’s really an unsung position.”

The success of – and support for – these middle management positions is also a key contributor to financial longevity.

“If you don’t have a good revenue cycle management team to fight with payers, with states and with Medicare to get paid, then you don’t have the cash flow to make payroll,” Anderson said. “Particularly within smaller agencies – where that might be a more local function – it’s critical. You have to get paid on time and you have to get paid fully. In a world of shrinking reimbursements, you have to minimize AR to have cash flow to pay your employees.”

Recruiting, retaining top talent

It’s important for agencies to not only hire the right middle managers but also to hold on to them.

The same McKinsey report revealed that 55% of managers are actively seeking a new role. At the same time, only 31% said they are being engaged at work.

“If you match up those cultural aspects, then you’re more likely to keep that retention at the middle manager level,” Griswold CEO Michael Slupecki said at Home Health Care News’ FUTURE conference. “Which I think also drives caregiver retention and recruitment. Everything flows from the top.”

The Blue Bell, Pennsylvania-based Griswold provides personal care services via more than 170 locations in 30 states.

Slupecki and his team take pride in their ability to have a good feel on this middle management team tier, he said.

“Our home office structure is only 30 people, and then we have eight company-owned locations that are operated by another 30 people,” he said. “For an organization our size, it’s really easy to keep the pulse on everything.”

When it comes to recruiting and finding good middle management people, Slupecki looks for two key qualities.

“I look for tolerant perfectionists,” he said. “There’s a lot of perfectionists out there that are very intolerant. Tolerance is something that comes with maturity. When we target those people at the mid-levels, we might have to coach them up on accepting the fact that not everybody is a perfectionist.”

Cultural tone setters

When John Kunysz says it out loud, he knows it sounds like corporate talk.

“What you absolutely have to do — as the C-level leader in your organization — is culture and vision orientations with your teams,” Kunysz told HHCN. “I know it sounds painful. I know it feels painful. But it’s worth it.”

Based in Dallas, Intrepid USA provides home health and hospice services, with over 80 locations spanning across 18 states.

Prior to the COVID-19 pandemic, Kunysz gathered all of Intrepid’s administrative staff, sales leadership, sales teams and clinical teams for three separate weekends.

During those meetings, team members were given an opportunity to get to know their colleagues. At the same time, those in middle management used that time to understand Kunysz’s vision and how to implement it.

“It was personalized,” Kunysz said. “It wasn’t a canned pitch. I did my research and knew who was an NCAA swimmer at Western Kentucky. Some of our people on those calls told me that they had never had that kind of connection with a CEO in their 30 or 40 years in health care. That kind of connection is what’s going to be required for us to succeed with these team members.”

Open communication also eliminates the space for gray areas in job performance and expectations.

“It’s really simple,” Kunysz said. “These types of strategies give absolute clarity of what’s expected.”

A lot of buzz terms that are talked about so often – innovation, growth, technology enablement – are only achievable with a healthy middle management team.

“The business graveyard is full of innovative companies that couldn’t execute,” Slupecki said. “To execute, you first have to have the right people on the bus. When you have the right team, you can supply them with the right tools and challenge them to be innovative. But always start with building the right team.”

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