S6E7: Improving Behavioral Health care among the most vulnerable: The Innovive approach

[Music] Coming to you from our beautiful Penthouse Studios at WXORJLP Northampton in Florence, Massachusetts, this is Care Talk with Quick & Quack. [Music] Welcome to Care Talk with Quick & Quack. I'm Dr. Evan Benjamin and along with my pal Dr. Bill Cutler. We're here to talk about health and health care. We'll be talking with each other with health care experts and we welcome your input in our conversations. You can email us at [email protected] to share your questions, concerns and experiences relating to our health care system. [Music] Good morning Evan. It's cold outside. What are we going to do in here today? It's wicked cold as they say, Bill. Well we have a guest today in the studio, Joe McDonough, who's the CEO and founder of Inavive Health, a really innovative model that he's put together for looking at behavioral health and the most vulnerable patients is going to have a great conversation with Joe. This sounds interesting. I'm looking forward to it. [Music] Good morning everyone. We have a guest today in the studio, Joseph McDonough, who holds a Master's of Nursing from Yale University and a Master's of Health Care delivery science from Dartmouth College, who's a real visionary entrepreneur and he's an innovator in health care, who's really transformed home health care over the past 30 years. Joe founded Inavive Health in 2004 to manage some of the most underserved populations in the country. These are individuals with complex behavioral health needs and also medical conditions. Company has become really the largest home health care agency in Massachusetts specializing in this population. He's expanding now in Colorado and Iowa with a real innovative care model that delivers patient-centered and data-driven care that emphasizes not only outcomes but ways to reduce hospitalizations and really trying to integrate the social drivers of health. Joe's learned how to partner with value-based organizations like ACOs and Medicaid plans to really try to create a value-based model for a very, very vulnerable population. Joe, McDonough, welcome to Care Talk with Quick and Quack. Well, good morning, Evan and Bill. It's an honor to be here. Thank you for having me on and really thrilled to be able to talk to you this morning. That's great to have you on the show, Joe. Welcome. So, Joe, want to talk a little bit about, first of all, you, a little bit about your origin theory. You and I got to know each other when we were doing this Master's of Health Care delivery science at Dartmouth. I was a physician doing quality improvement work and wanted to learn more about health care delivery science. I learned a lot through you about what was happening in home health at the time and some of the challenges. But I'd love to hear about how you got into health care, why you decide to get your Master's in nursing and how you got into home care a little bit. Sure. So, I grew up in a place called Wolver Massachusetts, which is about 12 miles north of Boston. Wolverine was working class town. And I really had a tight-knit group of friends that I grew up with and ended up on, and high school ended up on the high school wrestling team. And my senior year, our team won the championship and we had a really great group of people. But right after the season, you know, my friends got really serious car accident where two of my close friends passed away, were killed, another friend, quadriplegic, and but our whole core group of friends were really just traumatized, right? And so to this day, we get together every year and it's amazing how that impacted each and every one of us. But for me, you know, after that, I had a couple of years where I really struggled at depression, had all different things that I was dealing with as a young man. You know, and ended up getting a job in an inpatient psychiatric facility in Somerville, was a small psychiatric facility in Somerville and started working as a mental health worker. And I saw some really amazing things that were there. I mean, I dealt with people that were diagnosed with AIDS for the first time. I dealt with people that were seriously suicidal. I remember a case that, you know, one of the first cases that significantly impacted me is there was this young man named Charlie, who was my age at the time, he was 22 years old. And Irish Catholic kid that had just come out as gay, he had 10 brothers and sisters and large, very large family in Charlestown and they disowned him. Wow. And so he, him and he was very, he was suicidal, had a significant suicide attempt. And was there for about a month and I remember the last few days of, you know, when I was working with him, he, his mood improved. He was smiling, he was doing well and he was well enough to be discharged. And I remember he thanked me and shook my hand, gave me a hug and I wished him well. And then probably I think a few hours later we threw him some of the front of a train. Wow. And, you know, that stuck with me for a long time and because, you know, the world has changed, right? You know, you and I roughly are on the same age and you know, if he just lived long enough, he would have lived in a different world, right? And so, you know, I always wonder if he had home health care, you know, someone to work with him right when he got out of the hospital. If he would have, if he could have had a different, a different fate. And the other thing that I, that really stuck with me at that time is I saw the same patients coming in and out of the hospital. They would get discharged and they would come back like a week or two later. And so it was a revolving door and, and once patients were discharged from that hospital, there was really nothing in place to, to, to help them, you know, get better outcomes and, and, and become independent in the community. So after doing that for a few years, I decided I wanted to, to move forward. And so I ended up, and rolling at the, I ended up going to Yale University. They had a, a master's, a nursing program, a three year program where I could go and become specialized in psychiatry. So once I was there, you know, I, I saw a lot of, you know, I worked at the Yale Psychiatric Institute. I worked at Yale New Haven Hospital and, and being in New Haven. I believe you were in New Haven. I did my residency there, yeah. Some of those names are very familiar. Again, I saw really huge needs in the community that were not being met. And I started actually working in home health, you know, weekends while it was in school. And, and once I started working in home health, I, I realized like, wow, this is really the missing piece for, for this population. So, you know, I did that for a couple of years. I just did a jumper say it, it sounds like that, that was a very formative thing of, noticing that hospital care is essential, important for, for, you know, helping people out of crisis. But, but if the gaps are there outside of hospital, outside of hospital care, then all that work of the hospital care can really be, be of no use at all in the long run if you don't have the other pieces of the puzzle in place. Yeah, I mean, we'll talk about it in a, I guess a little later when we start getting into what we do, but really the hospital is the failure point, right? It's the failure point in the, in the continuum for other's population. Yeah, yeah. Well, I'm sorry, interrupted. Let's go on with your story there. So, yeah, I started, you know, so I, I, I did that for a few years and I moved up and I decided I wanted to start my own company, right? Because there was nobody in Massachusetts, you know, working with this population. Massachusetts has a very well developed home health system, but it's, it's mostly, it's mostly V&A's that are geared towards the Medicare Geriatric population. That's right. But the younger behavioral health population that, that, you know, tends to be unmedicated, there was really nothing in place for this population. So, you know, so I started this company in 2004 and really met a need that, that nobody really, really understood. And within a few years, we became the largest home health company in Massachusetts because we, we expanded very quickly and were able to, to really change a lot of patients' lives. You know, it's an amazing story, Joe. I, I actually didn't know a lot of that. When you went to nursing school, you, you were really driven by behavioral health that you, you're, you're desired, you, you're getting a master's in nursing and, but it was really about trying to improve behavioral health from the start. So, you really, you had this, you know, long vision over time and then start, then realizing that the, it's the home, that's the environment that we could actually do something in and founding of V&A. Like you said, most V&As focus in on more of post-acute medical problems, patients who are in hospital who are coming home, mostly Medicare patients, and eating some post-acute support. It's unusual to see. V&A really focused in on behavioral health and that was certainly your goal. Well, I mean, the quality of life for a lot of these people is terrible. And even to this day, there's real gaps in care for this population. They live in a whole different healthcare ecosystem than the rest of the population. And so as a young man, there were several patients that were just unbelievably tragic situations and they stay with me to this day and still drives me. And so you obviously realized that you needed also some more skills, leadership skills. You're founding a company, working on trying to innovate and change healthcare. What motivated you to get the masters of healthcare delivery science? Well, I realized that I needed more tools because we were meeting the need in Massachusetts. But I realized that Massachusetts is obviously a small state on the map and there's needs and really every other state in the country. So I realized that I needed to improve my leadership skills, my business skills, to be able to expand, to be able to not only improve the company and start looking at data and how that can drive outcomes, but to be able to expand and scale up nationwide, which is what we're doing now. Oh, that's fantastic. And Joe, we won't share the stories of our shenanigans up at Dartmouth when you and I were in class together. But we'll just say that we worked really hard. Well, I always resent it having to be the responsible one. You guys online. Well, you're lucky that you didn't have evidence of responsible one. Now, it really was a great program. You contributed so much to it. And you've done so much sense. So maybe we should take a quick, quick musical break here. And one of the things that we'll get into is I think some of the challenges of behavioral health, some of the challenges of home care and healthcare in general. What would you like to hear from music, Joe? The whole healthcare system in this population is under pressure. So let's play that. All right. Sounds good. This is Care Talk with Quick and Quack. Today we have Joseph McDonough with us from Inavive Health. We're talking about his innovative care model for behavioral health patients in the home setting. So Joe, welcome back. Ready to be back. Joe's under pressure. I'm sure for a reason that the healthcare system is under pressure. And you've been working with a particularly vulnerable population. Is the behavioral health patients who are mostly Medicaid patients. So Medicaid is the state and federal system set up for the poor. So I assume these are very challenging patients. And tell us a little bit about the challenges of behavioral health care in general and particularly for this population. Sure. So when you talk about being under pressure, right? I mean, hospitals are under pressure. You know, community health centers are under pressure. Primary care practices are under pressure. ED units are under pressure with this population. It's a very challenging population. Our patients on average are diagnosed with 10 to 12 different medical comorbidities along with a behavioral health diagnosis. And they're on an average of 10 to 15 medications. So it's a very challenging population that has generally very poor outcomes in the community. What was the age range of your patients in the community there? I think our average age is roughly around 55. But we've seen patients as young as 18. I think our oldest patient was 102 at one point. But mostly within people that are in their 30s, 40s and 50s. So a typical typical VNA works under a contracting model. They'll get paid from private insurance. They'll get paid from Medicare to really provide FIFA service, right? You go in, you can you take on certain services, nursing care, some physical therapy. Does Medicaid also pay the same FIFA service for home care and also for behavioral health? Yeah, Medicare and Medicaid are different. Medicare is more episodic. In nature, Medicaid tends to be FIFA service. So, in a vibe health is is exactly like a traditional VNA. We provide home health age. We provide occupational therapy, physical therapy, we provide nursing services. The only difference is we focus on the behavioral health population, which is a very challenging population. They tend to have high utilization as far as home health visits. We see patients, some patients we see daily, twice daily even, you know, on Christmas, our company probably did about 2500 patient visits Christmas. So, it's really a high touch model that's that is focused on minimizing hospitalizations, keeping patients out of the ED and really trying to improve their outcome and quality of life. I mean, we do a lot as far as assessing social determinants and how they impact our patients, you know, we're in their homes. So we're looking at, you know, how is their home set up as it is it clean, you know, do they have a roommate that's using drugs? Do they, you know, having working refrigerator? You know, do they have food insecurity? So, we're constantly, you know, assessing the patient's home and on earth is really apt as it is sort of the hub of the wheel in the sense that oftentimes our patients may have a primary care physician, they have a psychiatrist, they may have a diabetic specialist if they're diagnosed with diabetes or cardiac specialist. And I can't tell you how many times that it's almost 100% of the time that we'll go in for the first time and admit a patient and we will talk to all the different, you know, physicians that are involved or nurse practitioners that are involved in the patient's care and almost 100% of the time they've never spoken. Yeah, of course. So I'm a little curious about the journey that some of your patients may have taken to get into this program because obviously this is not, it sounds like this is not a program obviously for anybody who needs visiting nurse services and it's probably not a service that's there for anybody with any sort of mental health issue. It sounds like you've got a fairly high intensity population. So what are the criteria that bring people into your program as opposed to getting health care through some other venue? I mean, Massachusetts, for instance, is, you know, has a wide range of psychiatric services and really for the most part they do a wonderful job with this population. We specialize in the 3% of the population that nobody can manage and these are patients there that they could be hospitalized 12 to 18 times a year. There's, you know, they're in the ED every other week. You know, these patients, these 3% of the population probably drives about 50% of the costs in the system. So these are patients that have a very challenging time staying at home. You know, if you have somebody diagnosed, I'll be an example of a patient. If you have somebody that's 50 years old, they're diagnosed with schizophrenia, they have insulin dependent diabetes. Well, you know when you're discharged from the hospital, if they don't have our type of services in place, they're cognizant of even manage their group to go home. So, you know, if you're a doctor, never mind, try to correlate the score to the amount of insulin that they're supposed to administer. Right? And so it's an impossible mission for these patients when they get discharged to be able to stay out of the hospital. And that's where my company comes in that we create a seamless transition into the community. You know, we're the missing part of the continuum. Right? And as I mentioned earlier, the hospital is the failure point, right? I mean, the home really should be the epicenter of healthcare for this population. And so as I mentioned earlier, these patients are in a very fragmented system. Right? And there's a lot of silos that are nurses. They do a wonderful job, case managing and breaking down these silos to make sure that all the relevant stakeholders have the right amount of information. So that we can all get together and put a treatment plan in place that gives these patients the optimal chance of getting really positive outcomes. Because it's not about, you know, we do save, you know, the state and our insurance a lot of money. An average really for our patients and Massachusetts, we save about an average of 200,000 a year per patient in Massachusetts. I think the same amount in Colorado, a little less like I think about 50,000 a year in Iowa, but it's, you know, we're talking about 1000 patients that's significant, you know, we have thousands of patients throughout the company. That's a significant amount of savings. So these patients live in a very fragmented care system. And so that we work with everybody communicating, you know, connecting them with the services they need and really trying to improve their quality of life. Yeah, it's just such a model that makes so much sense. So you were running a state Medicaid program and you know, if your goal, if your goal was really health, right, not not just providing health care, if your goal was health, you would want programs like this, right, that we're looking at the full patient, the holistic view of the social drivers of health, getting them the right food. And then you know, a patient with diabetes, but they're living in a food desert, they don't have transportation. If you were running this program, you'd say, I want to do what I have to do to get these people healthy, not just pay for services, which is typically what's done. So the health care system is we've described on this show and Joe, you know, so well, the health care system is not, you know, our health system. It's a model, it's fee-for-service, it provides specific services and not looking holistically. And you've come in and said, "Well, we can do this differently in a home setting as well. It makes so much sense." And yet, this is not the norm. This is not the norm. You're innovating here. Is this a scalable model? Can others do this? And why haven't we seen this scale? A lot of Medicare companies, first of all Medicare pays better than Medicaid. So a lot of Medicare V&As, their cost structures really don't allow them to really work with this lower paying Medicaid population. And it's also a challenging thing. There's a lot of nurses that are not able to do this work. The nurses that we have are extremely dedicated. They're very dedicated to this population. We'll go into areas that most other V&As will not go into. I mean, I've actually personally admitted a patient by a dumpster at a McDonald's once. And so I've been in crack houses. We've really been everywhere. And it's just a very different care setting. It's amazing some of these environments where these patients, they really struggle to thrive in. And it could be a mile outside of some of the major hospitals in Boston, but they don't live in the same healthcare system. So Joe, you touched on this. It's obviously it's a challenging population who sounds like there's a lot of housing instability for them. There's food instability for many of these patients. Where the status quo without your organization is that there are a variety of different healthcare providers, perhaps from different systems, trying to provide mental health treatment, trying to provide primary care for them. And as you alluded to earlier, the communication isn't always there for them. I worked the second half of my career in the VA after working in a community health center and was just totally struck by the difference where mental health was integrated into the primary care process there. In the VA, they had a program called the mental health graded care management, which sounds like something similar to yours. These were would be nurses that mental health nurses that would go into the home to help care for patients. It was fairly strict criteria for them for people getting into that program. They had to, I don't remember the exact thing, but I think it was if you'd had a couple of psychiatric hospitalizations in the last year, you would qualify to get into that. I can remember it times being frustrated at the feeling that this program would be great for this particular patient, but he hadn't been hospitalized, so he wasn't going to get into the program. So I'm just wondering how people mechanically get into your program. So we get referrals from really almost everybody. All the major hospitals, primary care practices, community health centers, we get referrals from the department of mental health. They're vendors, the fire department, the police department. We work with really everybody, packed teams in the community as well. Any patient that has a need that's really struggling to be able to manage their care in the community that has a behavioral health diagnosis and qualifies for Medicaid, we will work with one of the frustrating things for us, and we're starting to work with some managed care companies, particularly in Iowa, to be able to do is data sharing with payers. One of the things that the payers don't understand is what happens when the patient gets out of the hospital, and we understand that, but we don't really understand a patient's history. So we're in a unique situation with some groups in Iowa where we're going to be able to really understand the full continuum. And understand what drives positive outcomes, what drives negative outcomes. For instance, we have data that shows that patients that are on our services for about 15 months. We stop hospitalizations altogether. Now I don't know why it's 15 months, and I don't know why that is. We need to do a much deeper dive on that because if we can do it at 15 months, I'd like to do it at three months, right? But that's something we really need. And I've talked to Medicaid systems in Massachusetts and Colorado as well to be able to do that. So that's something that we really want to be able to understand and really break through understanding what drives negative outcomes in this population. I mean, one of the interesting things that we saw in both in Iowa and Colorado, we expanded that to be in a Massachusetts so long. Some of the first patients we had in Colorado were patients that had thought disorders such as schizophrenia or schizophrenia-effective disorder, but they had diabetes. So we started seeing patients that were missing toes and feet and legs. And I said to my chief operating officer, Kristen Glambo, who's also a nurse and has worked with me almost 20 years. I said, Kristen, we don't see this anymore in Massachusetts. And she goes, yeah, Joe, because we stopped it. We stopped seeing patients for the most part. You don't see that in Massachusetts with this population as much or at all because our model and other models like it have stopped that in Massachusetts. But when you go to a new state, there are patients out there just getting their toes chopped up, getting their feet chopped up because they're not able to manage their diabetes. And by the way, a lot of this population, there are medications that cause weight gain or artificially sort of inflate the glucose levels. So it's a challenge and we've made a significant difference. The other challenge that this population has is they're not very good historians. And they're still really biases in the system where I remember one case. I told you about a case early in my career, but there was another case, this woman named Gail, who was diagnosed with schizophrenia. And if she was a wonderful woman, and frankly, she was very stable, but she had COPD and her oxygen level was low. So I had sent her out. This is early on in the history of my company. I had sent her out to be assessed in one of the hospitals in Boston. I instructed everybody to assess her. So she went in the hospital and they just literally assessed her psychiatrically. They never looked at her breathing or any of the other symptoms she was having. And she got discharged and then she ended up suffocating on her kitchen floor. Oh my goodness. And so there are many types of patients like that that just they just they're not getting the adequate primary care. So they're not getting adequate medical coverage and that's something my company really you know, focuses on to close that gap. So the nurses who work in your program when they go into the home, are they trained in skill to provide both the sort of the medical care for chronic lung disease and diabetes as well as the psychiatric care for the mental health conditions? Yeah. So a lot of our nurses come from if they come from medical surgical background, we really give them the psychiatric training. And if they come from a psychiatric background, we'll give them the medical surgical training to be able to work with this. So we put a lot of resources into education in my company. We probably do more education than any other any other BNA that I'm aware of because of just the unique challenges of this population. And how are you able to work the communication with you know with both the primary care? I mean, I take it. These people also have that they'll have an office-based primary care provider as well. And perhaps an office-based psychiatric care team. Is that right or? It can be right. I mean, each patient is different. I mean, remember a lot of these patients, they only see primary care twice a year. And that's really the challenge that we're trying to address because, you know, again, you'll have somebody go in to see a primary care position. They're poor historians. They're going to minimize symptoms. And so that's where our nurses come in. We know a patient's going to be seeing their primary care position. We'll give them a full report and status. You know, whether it's their block pressures or their glucose levels or whatever, you know, two saturation, you know, whatever the relevant, you know, data is, we'll give them so that they can better put a plan together to give these patients optimal outcomes. So, but a lot of these patients and it really depends. Some physicians have more bandwidth to work with this population in a much deeper level than others. You know, the system's overwhelmed. So it's a unique challenge. But most don't. And that's the sad truth of it. Most physicians don't have the bandwidth. Their practices aren't set up for it. But your model gives me, gives me hope. There's optimism there. Joe, why don't we take a quick break? I think you chose another song for us. Yeah, I chose better things by the kinks because I think we're going to really be able to make some really awesome changes throughout the country for this population. Great. Here we go. You are listening to Care Talk with Quick and Quack. We have a guest today, Joe McDonough, who is the CEO and founder of Inavive Health and Innovative Care Model, focusing in on behavioral health patients and Medicaid patients in the home setting. Joe, welcome back. This has been a fascinating conversation and I really want to pick up where we left off. This is a popular place. that many people shy away from, behavioral health patients, particularly patients who are supported through the Medicaid system, the system set up for the poor. And yet you took this on. You were probably told that you can't do this. You won't be successful. How did you think that this was actually going to be successful? And what was what was driving that? You know, as I said earlier, I mean, I'm very passionate about this population. And as I said that I was sick of seeing, you know, the same people going in and out of the hospital and not having resources available to them. And so, you know, I just decided that I'm going to just focus on this population and make it work. And it's not easy, right? Medicaid is a lower payer. You know, in Massachusetts, for instance, we're not paid very well for what we do, for the value that we bring the Massachusetts. As I said earlier, I think we save about $200,000 per patient per year. We, you know, cut down about six hospitalizations a year and eliminate almost all E.D. visits. So for the value we're bringing, you know, we're really not a reimbursed commensurate for what we do. And right now we're working with Mass Health about looking at, you know, piloting a value-based program, which, you know, I have some excitement about it's going to be small in scope, but there's the hope that it expands because, you know, from a value-based perspective, I would love to move away from the fee for service and be able to really capture the value that we're bringing these payer sources and state Medicaid systems. So just for our listeners, you say value-based, you're really meaning that you could take on the risk of managing these patients, but also as part of that, if there is savings, as you've mentioned, you are really eliminating some of these medical complications and admissions that you, as a company, you could share in that savings to support your model, right? So it's different than just being paid fee for service. If you're saving $200,000 per case per year in a value-based risk model, you guys would actually share some of that savings. I mean, that's the hope because, again, we do bring significant savings, but I also think within a value-based system, I think there's definitely a lot more opportunity for collaboration, right? We're stuck in a fee for service system that is very limiting, and I don't think it's necessarily appropriate for this population, because I think there's a lot of opportunity for us to be able to collaborate with primary care practices, with ACOs, to be able to do some unique things with this population. For instance, I would love to partner with an ACO and have a nurse practitioner visit these patients homes once a month to do primary care. I think there would definitely be obvious benefits to the patient, and there would be certainly benefits to the payer sources limiting costs. Yeah, you know, it is a very interesting thing when you have a combination of mental health issues and physical health issues facing a patient. When I worked in the VA, we did have, it was not a fee for service system, we had an integrated care system there. I can remember an example, which might be something like some of the patients that you serve. I had a really wonderful patient that I'd been seeing for years in primary care, who had chronic schizophrenia, he was well controlled on his psychiatric medication, very lovely guy. He had uncontrolled high blood pressure, and in working him up, I realized that he had a tumor of the adrenal gland, which was driving his hypertension. He was one of the rare cases of somebody who has high blood pressure that's actually surgically treatable. But in order to make the diagnosis and proceed with the surgery, he needed to go off of his blood pressure medications for, I forget, I think it was several days or a week. He was given that information from the specialty service, and they didn't really clarify with him which medicine he was supposed to stop, and he didn't understand, and he stopped his psychiatric medications. He had a psychotic break, was found by the police, hiding under a car on a cold snowy day in his pajamas, was brought to the local hospital where he couldn't even give his name, they didn't know who he was. This guy had just disappeared, we were in the VA, he was in a different healthcare system, didn't know what happened to him. After several days or a week in that system, he got back on some medication they learned who he was, they were able to care for him, and eventually got his care. But that's the type of vulnerability that patients with with coexisting mental health and medical problems have, and that's the population that you're working with, and it's the reason why they need this more intensive type of care, where you actually get to their home to see what's going on. That's a perfect example of the type of patient, so if you were working with us with that patient, you know, we could have kept him on the appropriate medications, we could have been communicating with you on a daily basis on a patient's status, we could have been monitoring the patient's blood pressure during that time, and it would have been a, first of all, we would have saved the patient the indignity of being out in the cold, and all the awful experience that was for that patient. But we would have saved the cost of the hospitalization, and we would have created a really seamless care transition for the patient. Right, and in our system, we didn't know that this was going to happen, but after that happened, he got into the intensive care management program, mental health that was there. So it's often hard to predict, I think that, you know, I'm sure that there are patients you see who have a crisis situation like that, and then they get into your program. You know, the unfortunate thing for a lot of these patients, they're very vulnerable, and you know, a lot of these patients end up in justice involved situations, and there's some real tragic stories of patients being shot and for being psychotic, because they didn't have the access to care to be treated and stabilized, and some really tragic stories out there. It just getting back to this model, you know, as Bill just described, the challenge of this one patient, and I'm sure you guys see this all the time with all of your other patients. You've been successful yet still in the current healthcare environment. You've managed this FIFA service with Medicaid rates, if you could get into some risk sharing that sounds like it would actually be a better payment model for you, but you've managed to do this, and you've got great outcomes, you're now expanding into other states. It seems like so many people, so many organizations could do this as well. What are the challenges? What do you think is keeping other VNAs or other health systems from setting up this similar holistic program? Yeah, I mean, I think what happens is, you know, hospital systems that have VNAs are bound by their cost structures. VNAs, which is most of them, that are Medicare-based, bound by that cost structure, in culture. And somebody asked me, would you ever start a Medicare program for your company, and probably won't, but if we did, we would almost have to have a PSC for a company because it's so different. It's such a dip, it's sort of in the same ecosystem of home health, but it's, there were other fringes of it. It's a very different care model than most Medicare, which cater to older, the geriatric population. Can you explain that a little bit more, you know, so this means, so if I, if I have a Medicaid health card, I get certain benefits with that. And if I have Medicare A and B and perhaps D, I get certain benefits with that. And so what I'm hearing from you is that is that if I was to access the type of service that you provide, the payment that you get would be very different if the card in my wall, it was a Medicaid card or if it was a Medicare card. Yeah, Medicare is meant to be short term intermittent care, right, for somebody, let's say they had hip surgery and they're getting discharged from the hospital and they need a nurse to go in on a limited basis to care for the patient. Maybe, you know, month or two until the patient is able to be more independent. But for us, because of this population, it's a very chronic population. So Medicaid is, you know, allows for krinicity and we've had some patients that have been on our services for almost 20 years. And, you know, and they probably will always be on our services because that's the top level of independence that they can, that they can attain. So you're saying that if you do a good job and take care of a patient, sort of get them through the crisis situation, then you want to, and then when they're on Medicaid, you would continue to provide ongoing care to make sure that the crises don't repeat themselves over and over. But if it was a Medicare patient, they would, they would pay you some for, for getting them through the crisis episode. But after that, they would say, okay, this patient doesn't, doesn't need this type of care anymore. We're not going to pay for that anymore. Is that, is that kind of the way? Yeah, so there's differences. So a Medicare patient also has to be homebound. That's one of the strict criteria for Medicare whereas Medicaid that's not necessarily, you don't have to be homebound and most of our patients are not homebound. And so it's two different models and that's what I was trying to explain earlier that VNAs have a very different call time transitioning to this population. So just from a clinical perspective, the homebound patient is somebody who is so disabled that they can't leave the house. But many of your patients, they're physically able to leave the house but because of the mental health issues, they don't have necessarily the capability to consistently provide their self-careing and go to many appointments and take care of themselves that way that if we rely on them to just do that without supportive services in the home, there's a high likelihood of failure. Yeah, I mean obviously every patient is different and as I said earlier, I mean a lot of our patients are on average, they have 10 to 15 different medications. And for smart guys like you both are myself that we would have a difficult time managing 10 to 15 medications. Two or three, two or three, but everything is not picked things up and you know whatever, it's a lot. So for our patients, you know again we may see them for a long time, we always try to the optimum level of independence. Some patients were able to graduate from our program and discharge them and they're able to self-manage their care. We can get them to that point and there are other patients that are always been in need of services and maybe you know instead of being hospitalized 12 to 18 times a year, we can get them so they're only hospitalized four times a year. That's amazing. Right and so we always try for the optimum level of independence for this population. We try to interact with our listeners, people email us at [email protected]. I just got an email from a listener. Once you know how you manage patients who may be houseless or homeless. Yeah, we work a lot with the end house population. We work with homeless shelters all throughout Massachusetts. We have a really wonderful partnership with the Spring's Rescue Mission in Colorado Springs, which is really doing innovative work with this population. We're working with some homeless shelters in Iowa and Des Moines. So yeah, as long as they haven't addressed that they can, that they're attached to, which is a lot of these shelters, we do a lot of work with this population. Again, it's challenging and a lot of times what we're able to do is stabilize them enough that they can qualify for more permanent housing. That's great. So you get the same model, but you're working with them and as you're looking, assessing their social drivers as well as their psychiatric as well as their medical conditions, you're also trying to support even transitioning them to more permanent housing as well. It's fantastic. I'm so impressed. I talked before about the financial success of this. That's a big challenge. And then scaling this. You're now in three states at other plans for more other states, partnering with others to replicate this model. Yeah, so we've expanded out to Colorado when I were in those two states that they're different states, but they have significant needs. For instance, Iowa is 51st in the country for lack of hospital beds for this population. And when I say 51st, they actually lack behind Washington, DC. In Colorado, has had a lot of struggles. Governor Paulus just put in a couple of years ago, has added 547 million to the behavioral health budget to focus on this population because they've had really poor outcomes. I think they ranked 45th in the country for behavioral health access to care. And so we look at a lot of different states. We're actually looking at Texas. We're looking at Alaska of all places. We're up in Anchorage a couple of months ago, meeting with the director of Medicaid and the director of the Department of Public Health. And we're looking at Nebraska as well. And there's several other states. But really, it's a matter of which states have the, whether it's managed care providers or the state Medicaid systems because Medicaid to remind your listeners is a state managed programs, federal programs, but it's managed by the states. So some states have much more supportive of this population than others. So we're focusing on those states. But there's a need really in every state in this country. So this has been so great. Being able to highlight your company and your model for those listening, you've been hearing Joe McDonough from Innovive Health, very innovative model. And I'm afraid we are out of time, Joe. So I just want to say a big thanks for joining us here in CareTalk. Well, Evan and Bill, it's been a real pleasure and hopefully we could do this again sometime. Thank you, Joe. It's been a great discussion. [Music] You've been listening to CareTalk with Quick and Quack. We come to you from WXOJLP North Hampton, Massachusetts. 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