Miriam Allred (00:10)
Hey everyone, welcome back to the lab. Today I am joined by Christian Sullivan, an account manager at Altra Home Care in Indiana. Christian, welcome to the show.

Christian Sullivan (00:21)
Thanks for having me, Miriam. I have been a long time listener, so I'm excited to get my shot at chatting with you.

Miriam Allred (00:26)
Yeah, thanks for being up for it. I'm going to put you on the spot with a lot of questions, but I was just telling you this is your bread and butter. You're doing it day in and day out, and so don't feel like you have to be anything that you're not. Just answer honestly and openly. Let's start with your introduction. People likely don't know you. You're a little under wraps, but I'm giving you the platform to introduce yourself and talk a little about your background, pre-home care, how you got here, and then kind of roles and responsibilities today.

Christian Sullivan (00:38)
Absolutely.

Yeah. Yeah. Well, like I said, I appreciate you having me on. I, like you mentioned, have not been in the home care industry, um, for too long. I came from a background in sales, mostly software and tech. Um, and so I find myself, uh, as I may have mentioned earlier, but, uh, find myself, in the home care space now. And I feel like a lot of the guests that I listened to sort of happenstance end up in home care, which,

You know, I think to me is maybe a different central calling. ⁓ but nonetheless, I ended up actually meeting the, one of the owners of our company at my apartment complex. our dogs became friends first. so they were playing in the field and, you know, made small talk and, learned that him and his brothers had moved out here to start a home care company. and I heard a little bit about the ins and outs of that. and he had asked me several times to, come join him.

while he was opening a second office on the South side of Indianapolis. Took a little bit. But after a while, I think I got tired of the sales environment in the tech sphere. took him up on it, joined as a recruiter down in our Greenwood, Indiana office, worked my way up from.

Recruiter to lead recruiter, which was basically a recruiter with a little bit more hands-on training for some of the new hires. And then we opened our third office in Kokomo, Indiana, back in March of 2024. And then I took over in August or at the end of August, and I've been here ever since.

Miriam Allred (02:21)
When I say account manager, people may pause, like what does that mean? The business structure of Altra is a little bit unique and the titles are a little bit unique as well. Explain kind high level, introduce Altra. You mentioned Indiana, you mentioned kind the office numbers, but give us a little bit more context about just like the landscape of the business.

Christian Sullivan (02:40)
Yeah, absolutely. So, so account manager, it's kind of a versatile title. I do a whole lot of backend stuff as well as a business development. So account manager, office manager for those companies that have like an office manager. I, you know, I do a lot of marketing as well for us. So I'm pretty much the person that handles all the high level backends dealing with authorizations and things like that, as well as marketing, business development.

⁓ and then pretty much anything that, ⁓ might go wrong and usually gets passed on to me. but Altra as a whole, ⁓ we are a home care agency. also, ⁓ recently in the last year or so lost launched Altra home health. so we are doing the, the prior authorization skilled nursing, ⁓ HH hourly stuff like that. sister company and then, Altra home care. Yeah. Yeah. So

Miriam Allred (03:29)
hours, yeah, hours and payers.

Christian Sullivan (03:32)
Yeah, so we do or we work with the VA. We work with Medicaid and we'll dive into the fiasco that is Indiana Medicaid at the moment and then private pay as well. So we cover quite a few, quite a few payer mixes. And then on Medicaid specifically, we have the Pathways for Aging program, which is pretty much anybody 60 and older. Then we have the Health and Wellness waiver, which is 60 and under, and then Traumatic Brain Injury waiver as well.

So those that have a TBI we can assist with as well.

Miriam Allred (04:03)
And is Medicaid your primary payer source or if you had to just kind of like break down private pay, VA, Medicaid, what's kind of the payer mix breakdown?

Christian Sullivan (04:12)
Yeah.

So it varies by office. My territory, Kokomo specifically is kind of mixed right now. We actually, we probably are 60, 60, 38 VA Medicaid split, 60 being VA actually in our area. With it being a new territory in the transition to the managed care entity model. You know, it's been a little bit slower of a go at it with the Medicaid side of things, but

Nonetheless, I would say as a whole, our bread and butter is definitely Medicaid, serving the Medicaid population. It's been an interesting last year and a half working with a lot of these new organizations, the big three, Anthem, United, and Humana. But it's been a fun journey, to be completely honest with you. So I enjoy it and I'm excited to see this continue to grow.

Miriam Allred (05:03)
You're one of few that say they thrive in the chaos. You didn't even come from healthcare. Now here you are, know, like running a Medicaid VA heavy home care company in Indiana. And it's just like, you know, the complexity of this industry. I wanted to ask you that like before you came in or when you came in, what was your initial take on just senior care in the state of Indiana? What surprised you? What worried you? What excited you?

Christian Sullivan (05:10)
Yeah.

Mm-hmm.

Yeah, I joined at a very interesting time because was right off the back of the pandemic. So, you know, a lot of people were getting a ton of services, which was, you know, great for business. But what ended up happening pretty much a year into when I joined was that the state of Indiana reconvened and looked at their Medicaid budget, realized they had over budgeted over about a billion dollars. So come

The end of what would be 2020 or the middle of 2024, when the transition actually happened, they brought on the managed care entity model, introduced the three insurance companies managing what used to be the aged and disabled waiver through traditional Medicaid now called Pathways for Aging. So when I first joined, it was straight Medicaid. So you had your aged and disabled waiver, your health and wellness, and then there's a slew of other waivers underneath that.

⁓ and then it was the VA pretty, you know, cut and dry, straightforward VA home care. and then private pay as well. yeah. So then once the, once the switch up happened, it was, basically like starting fresh, ⁓ trying to figure out, know, who we need to be contacting, who we need to be reaching out to. How do we, how do we get more referrals? How do, who do we call if, if an authorization doesn't come through or services are being stalled by the company. So it was, it was a big fact finding mission.

to figure out who the right people to get in contact were. ⁓ But like I said, I kind of enjoy the chaos a little bit. It keeps me busy, keeps me on my toes. So I've enjoyed it so far.

Miriam Allred (06:58)
You probably learned a lot from the owners and tapping into their expertise. What were other ways that you just educated yourself about home care in general, then also state-specific? What sort of resources online or in person did you tap into just to start accumulating all of this knowledge?

Christian Sullivan (07:16)
Yeah, so I may be a bit of a nerd in that sense where I actually just went through and read the FSSA handbook, which I think is, I don't know, 50 some pages of PDF. Let's read is maybe a strong word. I skimmed through it and picked out some major pieces really because when I started as the account manager up here, know, a whole lot of things fall on your shoulder with compliance and making sure that billing is accurate and all that good stuff. So.

Part of that was my own curiosity of trying to understand like, okay, what am I supposed to be doing on a day-to-day basis at the bare minimum to make sure that we maintain compliance? And then from there, I can kind of work outward, right? Because at end of the day, it doesn't matter how many hours I have, if we're out of compliance or billing's mess, it's not like we can, you know, bill for any of that or we won't actually get paid for it. So that was kind of where I started. Definitely leaned heavy on our owners who have been in the industry for a while. ⁓

their wealth of knowledge when it comes to anything, Indiana Medicaid and VA related. So they were helpful. I know our one of our other owners and our CFO has been in the industry forever. So anytime there's a little bit of turmoil in the industry, we always reach to her and she's been incredible just in sharing how to operate and then getting out in the community.

⁓ I think that is one of, if not the most valuable piece of, running a home care office is getting out and talking to the people that you're going to be servicing, talking to the people who have a vested interest in making sure that their family member or, know, they're, cause it's at the end of the day, it's people's aunts, uncles, moms, sisters, daughters, all of that. ⁓ and that has been one of the most valuable pieces, ⁓ just picking their brain, trying to see what their experience has been like.

⁓ you know, when, when the transition from the traditional Medicaid model to the managed care entity model happened, you kind of have to start fresh with who you're supposed to be reaching out to, you know, as far as dealing with their insurances and everything like that. So you have to reverse engineer it a bit, talk to them, figure out who their case manager is. And then, and then part of it is just being one humble, but curious. I think I walked into this in, in,

Miriam Allred (09:18)
Mm.

Christian Sullivan (09:26)
Maybe a fresh mindset because I hadn't been in the industry for long. So I kind of was just, like I said, curious, like, Oh, well, how does that work? How, who am I supposed to talk to you for this? How do I, know, what's the best way to bring up this conversation? So that has, Gotten me a long way just in my understanding of how everything operates. But two, think it just shows that people, you know, when you, when you are genuinely interested in what people are doing on a day to day basis and how you can best serve the client at the end of the day, think.

People, people tend to open up and help you as much as they can.

Miriam Allred (09:58)
Yeah, well said. I was just going to say you're a few years in. Keep the curiosity and the humility as long as you can, because I really do see the biggest, brightest, most successful leaders in this industry that have been at it for decades. They still have those two attributes. And so you have them now while you're like young and hungry and fresh. But as long as you can maintain those, it'll serve you. One more one-off question, and then we're going to get into the meat of the conversation. You started in recruiting and now here you are.

Christian Sullivan (10:22)
Mm-hmm.

Mm-hmm.

Miriam Allred (10:26)
like branch manager. So you've basically seen it all and done it all from like an operation standpoint. I'm curious which facet of the operation do you think is the most difficult? If you had to chalk it up to one thing from recruiting to billing to payroll to nursing, like which one thing is the most difficult?

Christian Sullivan (10:39)
Thanks

Yeah. if you ask me, I, you know, it depends. And I hate that answer. but it, it truly does depend, depends on your territory, your market, ⁓ you know, going from Indianapolis, which is greater Indianapolis, where you have, you know, a wealth of people, and kind of an endless supply of interested candidates as far as recruiting and people that potentially want to be caregivers. then

people that want services go and then you move up to Kokomo, which is, you know, 60,000 people, uh, maybe I think like 75,000 in the County alone. Um, it dramatically decreases the total amount of people that you can call on and recruit to from a recruiting standpoint. So I, you know, I, I applaud our current recruiters, uh, that are calling on a day to day basis. Um, really doing a good job of making sure that we have enough staff to staff our current clients. Um,

I would say...

Man, that's tough. I would say recruiting.

Miriam Allred (11:43)
Well, yeah, what if I break it down to

like sales? Because yeah, that's what you're like sales recruiting and then like back end operations. Like, could you even pick one? I know it all depends, but like if you had to like say of those three.

Christian Sullivan (11:48)
Mm-hmm.

Yeah.

I would say, I would say one thing that you don't realize is how much the backend operations kind of, I don't want to say bog your day down, but they, does truly like as you grow as an office and you have more clients, it's just more things that need to be checked, more authorizations that need to be managed on a regular basis. more clients that are calling in, ⁓ you know, it goes from a couple of hundred phone calls a week to over a thousand to, know, potentially, ⁓

1500 and 2000 phone calls that are, you know, our, our small team of three people in our office are handling on a day to day basis. So, um, I think just at it's a good problem to have growing obviously, uh, but the administrative burden on the backend definitely, um, it definitely kind of stifles a lot of the other front end efforts, uh, just as far as like marketing and because, you know, if I go out and do marketing, if I'm stuck,

sending out authorization requests or anything like that, or handling backend issues. Well, then that's another day that I don't get to be out in the community and try and, you know, provide as best of service as we can to our clients and then market. So I would say administrative burden definitely takes a toll on you on the backend. And yeah, I will say that's my answer. The backend administrative.

Miriam Allred (13:08)
Okay, okay.

Yeah, that's great. was talking to an owner yesterday in New Mexico, seven offices, and he was talking about wanting to step back, wanting to step back every time he does though, issues arise, fires arise, people issues arise. There's just this inherent stability of the agency and the operations. We talk so much about automation and streamlining and

Christian Sullivan (13:20)
Mm-hmm.

Miriam Allred (13:33)
consolidating, but it's like there's only so much of that you can do at the end of the day. It has to be Christian in the office, doing the authorizations, making the calls, reaching out in the community. Like there's only so much we can prepare back. And then it's just like manpower at that point.

Christian Sullivan (13:44)
Mm-hmm.

Yeah, I couldn't agree with that more. ⁓ I think, you know, this, this kind of goes to just the thought that I've had over the last couple of months, especially as you get through the holiday season, you know, you tend to step away from the office. You take your vacations, you're with family and you really start to see, okay, what are the pieces of the day to day that tend to break down? And maybe it's, maybe it's not even that there's a fundamental issue with the system itself. Maybe it's just the, maybe the information or how.

I relay the message to internal staff on like, we need to be doing things this way. And this is why maybe that wasn't clear at first. you know, when, when you have three people in one office trying to grow, ⁓ you kind of teeter on the point of, do we need another hand in here to help out with a lot of the things? And I think we're right there on the cusp of that. but it really comes down to that ownership of like, okay, maybe there's something that I tried to explain that didn't get through to them that I could do a better job of.

and so I'm constantly thinking about that, like literally every day, it consumes almost every thought of like, okay, what can I be doing better? How can I make sure that I'm disseminating the information accurately and properly to my team so that they have the power to be able to make these decisions and do, do the things that, know, maybe take some things off my plate. So, you know, authorizations are talking to VA case managers or Medicaid, service coordinators or anything like that. It's like, I want to empower them to be able to actually do those things one because it doesn't, it keeps them.

you know, dynamic and not static where they're just sitting around making phone calls. Cause it can be exhausting, like trying to find another caregiver on a day to day basis when you've, when you've called, 200 candidates over the last week, trying to figure out, okay, is this going to be the best one? Is this going to be the best one? It can be a disheartening in some sense. Um, but I think what we do well is we, try to make the office as a.

Autonomous as possible with who's able to make decisions obviously high level decisions kind of streamlined up to me but I want my team to feel confident that they can make a decision on a day-to-day basis and and know that it's gonna be right and accurate and also not feel like I'm going to come down on them for any stretch of the imagination because it is a big learning experience I learned by failing a lot and It was it was you know helpful because I think it

gave me the confidence to know, this is what not to do.

Miriam Allred (16:04)
Yeah, you make a lot of really good points. The way I think of it is bidirectional flow of information. When I ask you what the hardest thing is, maybe it's that. That's a piece of operations is how everything fits together and how everything is communicated between the different operations. I think that really is difficult. And like you said, it's keeping you up every night. think a lot of operators would say the same. It's just like, we communicating everything well?

Christian Sullivan (16:11)
Mm-hmm.

Mm-hmm.

Miriam Allred (16:30)
And is it flowing upward, downward, or crossword to everyone in the way that it needs to be? Let's talk about Medicaid in Indiana. I want to just pick your brain. It's been an interesting, like you said, early 2024, so about two years in, but it's ever-changing. There's so much complexity to it. I just want to ask you all sorts of questions. I want to just plug in here, though, and say,

Christian Sullivan (16:34)
Yeah, absolutely.

Miriam Allred (16:58)
You tell me, is this conversation relevant to private pay agencies? A lot of, you know, private pay heavy businesses might be listening to this. Do you think this is relevant to them or should they tune out? And is this only relevant to people that are doing Medicaid or are going to do Medicaid?

Christian Sullivan (17:11)
⁓ I think from a nuts and bolts perspective, it's probably relevant just to the people working on Medicaid. ⁓ however, I do think there is a piece of it, just in the form of how we communicate with our clients and the, and the case managers and everything like that, that can be relevant. We, not that we don't work with private pay clients because we have a lot. And in some sense, they are similar to just the dynamic, of the conversations that you have with them are very similar to, how we communicate with service coordinators and everything like that.

At the end of the day, think keeping, keeping the client as the center of attention, meaning we're doing our best to make sure that we're providing as top notch of a service as we can to that person. The, the backend doesn't matter as much as long as you keep that as this at the forefront. Right. So from a private page perspective and how we communicate, I think the biggest thing is urgency. we do get a lot of calls for private pay.

the, think the interesting dynamic, ⁓ for working with Medicaid is specifically that we have to keep our reimbursement or our private pay rates at what reimbursement rate is for Medicaid. So we can't undercut Medicaid. Otherwise, you know, they catch wind of that. Then they then lower our reimbursement rates specifically to what, our private pay rates are. So we, ended up losing a lot of business because of that, because there are other companies in the area that operate on VA and private pay only. and so I think,

That part of it is what it is, as far as, know, the pricing and everything like that goes. ⁓ but nonetheless, just, there's one thing that I can't stress enough. It's, and one thing that I've learned the hard way is over communication is always key. especially when you're dealing with the elderly population. I could have a conversation with someone at, 9 a.m. And then by 2 p.m.

They could, they could theoretically completely forgot that we had the conversation. so it's always like, all right, I need to make sure I double-checked with the family. I double-checked with the client themselves, making sure that they're aware of what's going on. Even if it's no update, a lot of times I'll call our clients just to touch base. How's it going? Hey, I don't have any updates for you. I just want to make sure everything's going well. I find that that conversation specifically ends up surfacing a lot of maybe tiny little nitpicky issues that.

could fester and become a bigger issue before it actually becomes that big issue. So I think that going in with that mindset of just communication being the most key piece to all of this can be relevant for, you know, private pay, but as far as like the actual day-to-day nuts and bolts, it's maybe not as relevant.

Miriam Allred (19:37)
Yeah, that's a good answer though. wanted to give private pay owners an out, but I think you're right. A lot of the principles that we're going to talk about are relevant across home care, across senior care. And a lot of parallels, we're going to talk about MCOs and what that looks like. In my mind, it's very similar to care coordinators and care managers that the home care agency has themselves. And just the dynamic of care and the communication you're already articulating. I think there's a lot of parallels.

Christian Sullivan (20:00)
Mm-hmm.

Miriam Allred (20:02)
So I just want the audience to understand, like, we're going to talk about Medicaid in Indiana, but there's going to be a lot of, principles here that do ripple across different payers and different states. to set a little bit more context, before a couple of years ago, there was the traditional Medicaid model, which was fee for service. The state came in and said, now we're going to go with a managed care model. Can you explain high level the

Christian Sullivan (20:05)
Yes.

Mm-hmm. Yep.

Correct.

Miriam Allred (20:31)
Well, there's gonna be a lot of key differences, but the key difference with the managed care model like what changed and How did that impact you like out of the gate?

Christian Sullivan (20:40)
Yeah. So when I first started with the traditional Medicaid model, there were the ⁓ areas of aging, your AAA, your local AAAs, right? Broken down and they had their handful of counties and whatever counties you service, there was kind of one entity that you could go to, to, get any kind of information that you needed, ⁓ managed, you know, NOAs, authorizations, things like that for your clients. ⁓ typically they were pretty easy to get ahold of. usually very willing to work with you, back in

It was, I think July 1st of 2024 is when it actually hit, um, when they transitioned from that traditional model to, um, the managed care entity model. Uh, what changed is every single member, uh, didn't matter what county they were in, or what AAA they were under, was then transitioned to one of the three major insurances that I mentioned, Humana, Anthem, and, uh, United. So.

It kind of consolidated a lot of the clients and you can be, as far as communication goes, a lot of that information wasn't readily available for us. So it became a lot like it literally like three months of, Hey, have you heard from your new coordinator at at the United? And they're like, no, I haven't heard from anybody. Okay. Well, your NOA is coming up for our expiration and we got to try and figure out who this is going to be. Otherwise services are going to get lost. Now.

They had provisions in place to actually make sure, you know, there was, don't know if it was till the end of the year or whatever the case might be saying, Hey, we're going to have the continuation of services. not going to let, you know, services aren't going to lapse or anything like that. Um, but what ended up happening is there was a wait list then for anybody that potentially was looking to get services. They were then put on this wait list. Well, with all the transition and all the administrative stuff still shaking out, you know, the, the wait list was 50, 60,000 people.

trying to get services because they cut the list. I think it was like only 27,000 and these are, please, if you're listening, look it up on your own. These are rough, rough guesses. Cause I haven't looked at the actual numbers in a long time and it's always changing. But, um, the gist of it was a lot of people had no idea what was going on. And, uh, from, you know, insider information, we were told that some of the MCEs were struggling to hire enough people to actually manage all of that.

Miriam Allred (22:34)
Yeah.

Christian Sullivan (22:55)
and that they were also supposed to work in tandem with the local AAAs. So the local AAA would go out and do the assessment. Then they were supposed to pass that information off to the MCE, and then they were supposed to be the ones providing, know, the, or doing a lot of the backend for the authorizations and everything like that. So a little, little bit of tension when you're, when you're told, your, your local agency is now going to have to pass all of its work off to this,

managed care entity. And to be clear, that's just for those that are on, that were on the Age and Disabled waiver. So 60 plus, anybody that was under that still operated under and still do operate under the local AAA. but it, it created a lot of chaos, especially with clients that we currently had because they were unsure who their service coordinator was, and it, I think one important note to make is that we see

one particular part of their service, right? So I don't see what their food service looks like, what their transportation service looks like or anything like that. I hear about it a lot and, and, you know, I'm obviously empathetic towards the situation as much as I can be. I don't necessarily get to control or have a hand in any of that, but it wasn't just their home care services that were potentially jeopardized. It was also all of their other Medicaid services that were potentially jeopardized. So there was a slow transition to that and

to the credit of the state of Indiana, I think they have done their best to try and manage all this transition. I can say with certainty that, ⁓ most people are not happy with the transition because it has caused more headaches than anything. but, ⁓ it's definitely a learning curve and it's literally always changing.

Miriam Allred (24:35)
Okay, okay. A lot of questions here. to make sure I understand and just like kind of lay the groundwork here. So before Medicaid fee for service models, traditional Medicaid, they were paying you and you were doing, you what was in like your jurisdiction. Now it's the state is paying the MCO or the MC entity and they're paying you and they are managing all of the care. Did you have relationships with those three companies, the MCEs before this or no?

Christian Sullivan (24:38)
Sure.

Mm-hmm.

I think as much as you know, we tried to reach out and get as much, know, network as much as possible. I think one of the the riding on the wall for a lot of the ⁓ case managers that were at the local AAAs were, hey, if we might need to jump ship to the one of these managed care entities, otherwise, we might not have a local AAA anymore. Not that I think they're going away, but they definitely shrunk the footprint that the local AAAs had. So

it was beneficial for us when some of those case managers jumped ship to one of the big organizations because we were able to keep in contact with them. And in many cases, we've kept good relationships with a lot of them. you know, it wasn't necessarily that we were going in completely blind. We did have some people working for these different organizations that we were able to get a little bit of insider information. But I think just the transition in general was pure chaos. ⁓

Miriam Allred (25:57)
because the employees at the MCEs also weren't like primed for this. So you're reaching out to them, they don't know what they're doing. You're telling them how to do their job. And so that's kind of my next question. At these MCEs, there are care coordinators that are now managing the care, managing the hours, managing the authorizations. You have to go out and build individual relationships with each of those people, or is there...

Christian Sullivan (25:57)
And so.

Nice.

Yeah.

Miriam Allred (26:23)
kind of like a management layer that you build the relationship with and overseas all those care coordinators?

Christian Sullivan (26:27)
Yeah, they're definitely a little bit more guarded on who gets access to them. ⁓ So if you're lucky, you get to chat with a manager of a specific area. I think the one interesting piece too is and makes it difficult for us is that it's not broken down by like county or anything like that. So I could be, I could have a great relationship with the service coordinator. We have a mutual client or a couple of mutual clients and next week she's actually moved to a different area.

and she's overseeing these new clients now. And so I call her, Hey, what's going on with this authorization? And she goes, I don't manage them anymore. It's like, okay. do you know who does? And they're like, can look it up, but I'm not sure. And so it's a lot of just turnover on the inside, a lot of chasing, correct. Trying to figure out who's who, what you're supposed to do. I mentioned before we started recording, but United specifically, did like a little merge of the roles.

Miriam Allred (27:10)
Chasing, yeah, chasing these people down.

Christian Sullivan (27:21)
⁓ from a care coordinator, service coordinator to just basically a one care coordinator managing out all of it. and so that has caused a lot of chaos because I, from my experience, some of the care coordinators didn't know how to do a lot of the backend stuff. you know, we had a client sit on hold for two months waiting for an NOA, not that they had any problems with, like their home or anything like that. It was purely because we just couldn't get authorized for services.

So that's caused a lot of tension.

Miriam Allred (27:50)
Can we illustrate this with your territory specifically? think of your territory. How many clients do you have and how many individual care coordinators are managing your senses of clients? Because I'm curious what the ratio is.

Christian Sullivan (28:07)
Yeah. So I have, and this is, so let me, let me preface this. My territory specifically, Kokomo is kind of the heart and soul, the center of where we are. Now we specifically put an office here because our, reach is pretty wide. So my territory covers, and for anybody listening that most people listening I basically cover border to border, East and West.

⁓ so I cover, roughly, think it's like 300 miles or something like that. Big territory. What that means is that that covers three different triple A's. ⁓ and it also covers many different, just units inside these different care entities. And so, as far as like getting ahold of people, know.

We happened to have a case manager that was working for one of the local AAAs that went to United. now she's a manager overseeing one of the territories in my area. So that's been a nice connect because I've been able to reach out to her and get a hold of a lot of contacts on her team. The problem is that a lot of the other areas are pretty guarded and getting information. So for instance, Lafayette, West Lafayette, for those who don't know, that's where Purdue University is. That has been.

probably the hardest area to crack into because the local AAA won't give any information out. said, if you're on the pick list as an agency, someone picks you, we'll call you. It's like, okay, but there's, I don't know, 72 in your area. You're telling me you're going to help give a list of 72 agencies to, potentially elderly couple looking to, Hey, pick one of the agencies. They're like, well, which one's good? Well, we can't give recommendations. It's your choice. I couldn't pick that.

So it's been stressful just trying to develop the territory in the office and everything like that. But overall we have about, I want to say 73 clients at the moment. with that, a lot of them on hold at the moment, just because of the different issues with authorizations and Medicaid services in general.

From that, would say from, on a United's perspective, like their specific case managers, I have probably 25 contacts there, ⁓ just for one specific area. That doesn't include the rest of the territory. It's, it's, I'm still uncovering new people to talk to regularly. And part of this is the, the fun caveat that they, that has been happening is that members will just change insurances at the beginning of the month.

But it's usually retroactive to last month. like, for instance, I had one member change three different, he went through all three MCEs in the span of like two weeks. So from a billing perspective on the backend, I have to go back in, change every service on his care plan in the system. And then I have to go back and make sure that the correct care plan is selected for the shifts. Then I have to change every single shift. And then we have to resubmit the EVV data and then resubmit the billing. And I don't necessarily handle that. That's our lovely CFO, but

I promise you, she is not thrilled.

Miriam Allred (31:05)
Yeah. Okay. So that's the context I was looking for. You know, big territory, 75 clients, then 25 relationships in one territory with one MCO. the amount of relationships you have to have, you haven't even like uncovered all of them, but the ratio is huge. I was curious, you know, is it like five people you're talking to? Is it 20 people you're talking to? Like it's a ton of people managing the care, know, like hands in the cookie jar here and

Christian Sullivan (31:25)
Mm-hmm.

Yeah.

Miriam Allred (31:33)
You have to find them, build a relationship with them, and then the real work starts, which is managing the care, which like you say is like a moving target with the plan and the waivers and then being able to change plans as well.

Christian Sullivan (31:42)
Mm-hmm.

Yeah, it's a, the, the kind of the spider web that you have to weave when, when trying to build relationships with the managed care organizations is, incredibly nuanced, because you're dealing with, most cases, nurses that they also want to provide the best care for their client. And I'm one agency trying to do that. They're working with, in their area could be 20 different agencies also doing the same thing I'm doing. So.

I always try to be as collaborative as possible. don't ever want to, you know, be the, I guess sales background calling in and be like, Hey, you got any referrals for me? You got any clients? What's going on? How are you doing? It's always, Hey, how's everything going? How's, know, you try to build that personal relationship with them. and just, I always try to reiterate, look, look, we're on the same team. We're trying to provide as, as good of care as we can to our clients. I I'm someone that is.

I think rising tides raise all ships. If we can't be the agency or the organization to provide that quality care, I'm never going to be someone that's well, let me keep trying. Let me do this. Let me try this. I'm, Hey, if you got someone else that you think can do a better job than us by all means, go ahead and let that, let the client, choose that agency. And then I'll probably reach out to the agency and be like, Hey, what are you guys doing differently that, that maybe we can learn from not everybody is willing to divulge all the information, but I try to build.

Miriam Allred (32:57)
Mm-hmm.

Christian Sullivan (33:02)
as many relationships just in the industry in general as I can, whether it be with other competitors or different hospice companies or things like that. Because at the end of the day, if someone calls my office and I can't provide services for them, I want to know and trust that, hey, you can call Sheila down the road. She's got someone that, or she might be able to help you out. Because in my opinion,

If you, like I said earlier, if you, if you keep the client and the client's care at center of mind and know that you're trying to do the best that you can to provide them services, should matter who's doing it. As long as that person's getting the best care as possible. Um, so that's why I mean, it's worked well. Um, I've been able to build a lot of relationships in the area. Um, you know, grow our office to, like I said, 73 clients. Um, we're not doing a ton of hours mainly because the VA and the Northern Indiana part of the state, uh, loves to give out like three hour cases.

⁓ and you kind of have to take those to get the bigger ones. ⁓ so it's, it's been interesting.

Miriam Allred (33:58)
Mm-hmm.

The other layer is that every one of these MCEs the rates and the reimbursement rates are different, correct? There's not like a standard and so Every single case comes with kind of like its own unique rates and reimbursement rates

Christian Sullivan (34:16)
Yeah, it's so that's a good point. And I probably should have brought that up during this. So just before the switch, the MCE's happened. Indiana changed. They basically went from a tenant care services as a blanket to a tenant care and home and community assistance. So those both have two different rates. A tenant care, believe, is $36.34 home and community assistance, $31.72 maybe. And.

They basically transitioned from one blanket rate to two separate services. then on an operating standpoint, you now have to, and each service has a specific tasks that you can actually provide services for. And unfortunately, and what we're seeing right now, especially as the new, guess,

rule came out with the hour by hour designation for tasks being done is okay, but what tasks are allowed during what times and how are we supposed to schedule that? Cause on a schedule it's, it's one block of service, but the client's daily needs change. You know, let's say if I was a client and I, Hey, some days I wake up and I like to sit and drink my coffee and then I don't necessarily need to get bathing assistance until later in the day. But some days I wake up and okay, I need bathing assistance that day.

How is the office supposed to know? Okay. What is supposed to be done on what time? then we're scrambling to make sure that.

Miriam Allred (35:38)
and the state

is trying to control that.

Christian Sullivan (35:41)
So the state basically came out with a mandate over the, it was, think at the beginning of the year, basically saying we need hourly documentation of what the care plan is. So basically whatever task is completed in ⁓ any string of an hour. like from eight to nine, what was done during that hour? From nine to 10, what was done during that hour? It's like, how are we supposed to police that?

Miriam Allred (35:59)
Mm.

but they're not dictating what gets done in what order. For a second, I thought you were saying they dictate, you know, bathing has to be done between eight and 10 a.m., but no, it's just that they want to understand what's happening hour by hour.

Christian Sullivan (36:11)
You get it.

Correct. And the MCEs, they do send like an initial care plan of like, the client would like this done at this time and this done at that time. I've been there when the case managers have been there. It's they're not as strict as the documentation says. And again, I think a lot of it ends up just being detrimental to the client themselves because things change. You know, if you have a client that has, let's say they have Parkinson's, some days they have good days, some days they have bad days.

good days, you might not need to do as much. You might just be kind of standing around making sure they're not falling or they're not a fall risk or, you might help with transfers and things like that. Other days, you might need a complete transfer. Like they might not be able to get up at all. So I think the dynamic of the day to day changes. and it's, it's, I understand the point of why they're doing the hourly documentation. know fraud and in Medicaid specifically has been a huge topic, just kind of across the U S in general.

and I get why they're, why they're doing it. I think practically it's incredibly difficult to enforce. and then it, exactly, exactly. And at the end of the day, what I think it does is it just, it just causes more administrative backend burdens for first agencies. And, know, if I guess if I'm wearing my tinfoil hat conspiratorial, I think they think that's a good thing because a lot of the mom and pops, that rely on, you know, a couple of clients here and there.

Miriam Allred (37:14)
They're not running home care companies. have no idea what the day-to-day application looks like.

Mm-hmm.

Christian Sullivan (37:37)
They can't afford to not be providing a service and trying to keep up with all of the changes. It's difficult. And we're lucky we have a great support team to help with all that.

Miriam Allred (37:49)
So one more question on the rates and reimbursement to make sure I understood it right. It doesn't vary by MCE to MCE. It's just the plan and the service offering that dictates the rate. So United's not putting up rates for these services and Humana's got different rates for different services. It's just there's a rate and a reimbursement rate attached to each service and it doesn't vary by MCE.

Christian Sullivan (37:52)
Yeah.

Correct. think I do remember when the MC model was being kind of introduced. There was talks at one point where depending, like you could theoretically negotiate for a rate based on outcomes of your clients. So like if we have, if we can show that we have good outcomes with our clients though, you know, we could potentially negotiate.

I don't know if that's still on the books as something that they're looking to do down the road, but as of right now, it's still just, you have a tenant care services. It's reimbursed at this rate. You have home and community assistance hours. It's reimbursed at this rate. Doesn't change from MC to MC. now the total amount of hours that a client gets approved for might change. I guess the, the big, overhead kind of piece to this is that, with Medicaid,

being pair of last resort and on the kind of the rung of the ladder. there's three big kind of key components of this. There's prior authorization, PA home health services. Everybody's basically pushed to that first. Then there is, ⁓ your structured family caregiving. So do you have someone living in the home that we can just pay flat rate monthly to take care of you as nursing oversight? ⁓ it's not as strict as PA necessarily.

Um, as far as like all the documentation, everything like that, but it's a little bit more structured and then Medicaid, um, uh, attend a care and home and community assistance hours. The, you know, I guess the wild west is not the best way to describe it, but it's kind of similar to that where it's typically reserved for those who don't have family close to them as well as, maybe don't have, if they do have family, they're busy, right? They have lives, they, they work, they do this. So they don't necessarily have someone to take care of them on a day to day basis.

The idea was that everybody's going to be pushed to PA because it's more regulated and structured. And it's an easier way to kind of control who's getting what services. what that's ended up doing is it's, it's caused a lot of just kind of chaos on, that side, because we're now having to apply for PAs on the home health side. And then half the people don't even qualify. So we get, get, I'll get a call and I don't even manage any of the home health side at all.

We work kind of in tandem because a lot of our clients kind of share services, but they'll say, Hey, they need a, their hours are going to get cut on the Medicaid side or on the attendant care side because they have to have PA hours and it's happening next month. You're like, uh, okay. So then we have to apply for PA PA hours. And they go, well, they don't even qualify. And they're like, Oh, you just have to show that you apply. it's like, well, what was the point? What was the point of all of that kind of ring around the Rosie just to be back where we're at now?

Miriam Allred (40:43)
Hmm.

Christian Sullivan (40:48)
⁓ so they are, you know, in some cases they are allowing, depending on the MCE, they are allowing, you know, 40 hours of attendant care, you know, for instance, someone's wheelchair bound or a quadriplegic or paraplegic or something like that. but a lot of MCEs are cutting off the total amount of, ⁓ tenant care hours at 20, and forcing them to basically go get PA services, which is again, more structured.

Miriam Allred (41:11)
You mentioned that like hierarchy, home health, then kind of like the family model and then the home care model, essentially like those three in that order. Who's pushing that hierarchy? Is it the MCEs or is it the state or is it like market demand or is it purely like budgetary?

Christian Sullivan (41:15)
Mm-hmm.

Again, I don't necessarily know specifics on that. If I had to guess, I would imagine it's probably the state, just Medicaid in general, the state of Indiana's Medicaid funds, specifically because of the over-budgeting. They're looking for ways to more or less cut back on hours. I don't want to necessarily speculate on exactly what's happening, but...

If I had to guess, it would be, Hey, we can control the very least. we're to be funding services with PA, we know exactly what's being done. And it's being approved by a doctor, their primary care physician with Medicaid. It's, it's being approved, but it's as I mentioned earlier, it's like, how do you police some of that stuff? ⁓ and so that's where I see kind of the baby being thrown out with the bath water where a lot of people that still need the services and maybe don't have the support system or maybe they don't necessarily have a need for.

Miriam Allred (42:16)
Mm-hmm.

Christian Sullivan (42:28)
for home health services, but they definitely need help more than 20 hours a week. Well, some, in some cases you're, you're not getting it or you're not getting as much as you want. So we have to be creative on our end to figure out, how are we going to staff this to make sure we're trying to give you the best health outcome as possible with, you know, both hands tied behind our back.

Miriam Allred (42:50)
So you're about two years into this model. The goal is to improve the quality of care. I'm curious if you think that's happening now or will happen. From my perspective, it's like there's still all this tension, there's still all this chaos, everyone's still kind of fumbling their way through. And I'm curious, do you think the care has already improved or will continue to improve?

Christian Sullivan (43:04)
Yeah.

Um, in short, no, I don't think it's improved at all. Um, a couple of reasons for that one. I mean, I've again, if I'm being cynical, I've seen clients get kicked off Medicaid in general, just, you know, if we have a bed bound client that can't get their own mail and their Medicaid goes ineligible because he didn't fill out the paper that got sent to him in the mail, what is he supposed to do? Crawl his way to the mailbox and fill that like,

We've been in an afford. I wish I was making that up, but I'm not making that up. That's I've seen that happen time and time again You know clerical errors on the Medicaid back end. There's like, oh, sorry You're kicked off Medicaid for right now and we'll figure out what's going on and then you know, the clients freaking out I'm not gonna get services, you know In some cases, you know some clients they're okay, right? They may not necessarily they'll survive which At the end of the day, I think it's

I think it's wrong in general, but, um, in other cases, we do have clients that completely rely on us to be there for them to help with every activity of daily living. And if we're not there, it doesn't get done. And the reality is that some of those people are losing their Medicaid or, the MCEs aren't, they're not getting their authorization sent to us in time. So it's either we send the caregiver out and eat the, eat the cash on our end. Um, and, or, you know, in other cases, like, oh, we'll reimburse you.

And then it's like, okay, cool. And then we send the caregiver out there and then two weeks goes by, we finally get the NOA and they're like, actually we, we can't because something happened and we just can't. you're like, what are we doing? we're in a position where we can, we're big enough to where we can, you know, occasionally if something like that happens. Okay. But if they're strategically asking us to sacrifice two weeks of pay, hoping that they'll reimburse us, like what small agency is going to be able to survive that.

Miriam Allred (45:08)
Mm-hmm.

Christian Sullivan (45:09)
And the answer is none. They're all like, we've seen so many shut down specifically because of that. And it's been, I think to speak on that, I don't think anybody's health outcomes are improving when less care is being provided.

Miriam Allred (45:23)
What about transparency into the holistic care? You mentioned earlier with the traditional Medicaid model, you knew what their home care services were, but you had no idea about meals or home health or additional services. Now with the managed care model, in my mind, it hopefully gives you more transparency into the overall care of the client. Do you feel like there's any more transparency than there was before?

Christian Sullivan (45:51)
Not really, to be quite honest with you. And I don't think part of that is that they don't want to be transparent. I think part of that is when you have a different service coordinator, care coordinator every other month, it's pretty hard for all that information to be passed along regularly. I think, like I said, I don't think anybody's health outcomes are particularly improving, which

Again, if I'm being cynical, I don't necessarily know if that was the reason why they switched that. I think it was purely budgetary. unfortunately they had to do what they had to do. And I think it's ended up costing a lot ⁓ of people services that probably otherwise would be getting services still, or at least more services to help them. it's frustrating because at the end of the day, like in my heart, I want to make sure that I'm providing the people that rely

for services as good of service as we can provide them. when we get our hands tied behind our back, you have to make tough decisions sometimes. It's not always the best one, but I do know that we fight pretty hard for our clients to make sure that they can get their services they're looking for.

Miriam Allred (46:50)
Yeah, it's a tough, tough reality. mean, at the beginning of the conversation, we talked about your curiosity and your passion and your fire for this. But then, you know, we talk about the nuts and bolts of what this really looks like. It's exhausting. It's really difficult. And I want to talk about kind of like a day in the life for you. Think of like your day to day or maybe like kind of like a week time frame. What does that look like? How much time are you spending talking to these?

Christian Sullivan (47:02)
Yeah.

Miriam Allred (47:16)
care coordinators, how much time are you spending on authorizations and billing? Like if you had to kind of quantify like what your week looks like, I'm curious what that looks like. Just so people understand like, you know, your day to day, what does this actually look like if you had to kind of quantify your time and where it's spent.

Christian Sullivan (47:17)
Mm-hmm.

Yeah. Um, I would say right now, I would say probably 60 to 70 % of my time is spent, um, just talking with clients, um, about their services, talking with, um, managed care entities about their services. I would say that's, that's probably a good estimate. 70, 60 to 70, 70 % we'll let, we'll stay on seven. Yeah.

Miriam Allred (47:53)
Can you break that down by clients and MCEs? even just,

is it like, is that a 50-50 split or less time with clients and more time with the MCEs?

Christian Sullivan (48:02)
I would say it's probably 60, 40, care coordinators to clients. the reason being is there's only so much I can share with a client if I don't have more information. So like I mentioned earlier, a lot of my conversations are, Hey, I'm checking in. How's everything going? Any issues? No. Okay. or if there is an issue with the service, which we've been dealing a lot with lately, it's

calling them to say, you know, I reached out to your care coordinator. I reached out to their manager. reached out to the, the United healthcare hotline and let them know. And they said that they were going to, you know, make it a priority list and whether they do or not, have no idea. But, I, at the end of the day, I think they want reassurance that someone's trying to help them. I mean, they're vulnerable. They're in a vulnerable position and, someone else needs to help make, make sure their voice is heard. So I think a lot of that is.

calling the care coordinators and their insurance companies and trying to fight with them. And, so I spend a lot of time on the phone. if it's, if you're calling the, one of the hotlines, you're probably going to, you're in for about an hour of just waiting and holding and being transferred. that's this department. that's this department. You're like, okay, can someone just please tell me.

Miriam Allred (49:09)
Like for all of us,

if I call United right now, my experience is similar to your experience. I guess I was hoping it's a little bit better because you have an authority and a position that should warrant more, but it sounds like...

Christian Sullivan (49:21)
Yeah, occasionally

it's occasionally you'll find one one person that's like, Oh yeah, I'll help out with that. For the most part, it's a lot sitting on hold a lot of times it's a lot of talk and you never really get an answer. You're like, so are we going to get the authorization or not? And they're like, Oh, well, I got to submit it to the secondary review team. That'll take two weeks. And you're like, okay. Um, what am I supposed to tell the person that needs help today? two weeks.

Miriam Allred (49:48)
Mm-hmm.

Christian Sullivan (49:51)
OK, all right, right now.

Miriam Allred (49:53)
So what do you go

tell the client? What do you tell them?

Christian Sullivan (49:57)
I mean, I try to just act in transparency. Hey, listen, this is the exact conversation that I had with United or your care coordinator, whatever the case might be. I'm going to make sure that I follow up with you every week, once a week, just to touch base, let you know what's going on. know, hey, you know, this is the caregiver we're thinking about sending out there. These are the hours. Has anything changed? You know, because things can change on a weekly basis, right? So what happens in the care plan we established today might not be the same in six weeks.

Right now I know some come, I think Anthem is usually pretty good about sending over anyways, and like a 10 days ish 10 10 ish days. Humana is they're all over the place. ⁓ and then United is roughly four to six weeks. So I could go out to a home, meet a client, tell the care coordinator, Hey, we, just met, you know, we're good to get services started. Like, all right, well the, I'll get the NOA process that'll be there in four to six weeks.

And you're like, okay. what happens if, you know, unfortunately, like I've had clients pass away. What happens then? ⁓ sorry. Like from a human to human standpoint, like that's brutal one. but two, from a business standpoint, it's like, okay, well we just spent an immense amount of time and effort high, like making sure that we had caregivers lined up a lot of times. Cause it's not like we have caregivers just sitting in reserve waiting to work. Like the caregivers that we hire want to work. So

A lot of the conversations that I used to have and now my team is having on a day to day basis is coordinating those services and like making sure that we're, if we're, if we have to move schedules around to make sure that happens, then, you know, that's a lot of phone calls back and forth. Sometimes it's 10 phone calls because you're all right. Let me call this person. All right. Let me call this person. You just keep going down the line. So, um, it's just, yeah.

Caused a lot of chaos and I straight way off topic on that. So I'm sorry. As far as my day today, I would say that. Yeah.

Miriam Allred (51:48)
That's okay. You said the 60 to 70%, yeah, clients and then

care corners, MCEs and then yeah, the remainder, where is that focus?

Christian Sullivan (51:59)
Yeah. the remainder of that is usually double checking, authorizations to make sure like from a billing standpoint that we're actually going to be able to kind of recruit the revenue. or I wouldn't say recruit, but bill for it and make sure that it's going to go through. so there's no issues on that end. ⁓ and then marketing, I usually try, if I'm going out to a client's home, I usually try and say, okay, where are they located? Let me go do some marketing in the area.

go try and make some connections, go reach out to people. A lot of times too, I'll call some of the MCEs, like the case managers that I do have good relationships with and say, I'm going to be in your area. If you're free, I'd love to chat and just see how everything's going. ⁓ I think a lot of times when you're over the phone, purely over the phone, there's kind of that human level that disconnect where getting to see people in person and talk to them in person kind of adds a different element to it that I think sometimes this industry lacks.

Um, so I enjoy getting out to, do that and, and network. I would say, unfortunately, the majority of my time probably should be spent networking. Um, but at the end of the day, you know, we've to make sure that the business runs on the backend. So I spend a lot of time doing that as well.

Miriam Allred (53:04)
Yeah,

the reality is a little bit different. Are most of your referrals coming from case managers at these MCEs or not? This is the heart of your business model. Are a lot of your inbound referrals coming from these people or have you sought out other referral sources that are generating more leads for you?

Christian Sullivan (53:08)
time.

Yeah.

Yeah. So we try to be creative and not in the, in the sense of, we were doing this thing. No one else is doing more of like, you know, I guess if you've ever played basketball, they always say feed the hot hand. You know, if I'm calling on some case managers talking about services with current clients and I mentioned, you know, we got, we got some caregivers in the area that are looking for some work. Do you have anybody a lot of times it's like, actually, yeah, you know what? I have this client or there is a bit of a delay effect.

And it's, hard to track because I might have a conversation with someone about a current client and say, you know, we've got some, some, caregivers in the area that are, you know, maybe wanting to pick up some extra hours. Do you have anybody that say, ⁓ I don't know off the top of my head, but I can look two weeks later. I might get a referral from them. So the delay can be difficult to quantify sometimes because you never really know if your efforts are in the moment worth it.

So you just, you have to stay active on the referral basis and just keep calling. I know we do reach out to a lot of, like I've visited a lot of hospital systems in the area surrounding towns just to touch base. A lot of that stems from just like a random one-off call or they'll, Hey, do you guys provide services for this? And I say either yes or no and say, but you know, we actually provide services for this and Hey, actually I'd love to come, you know, meet you in person and

and maybe grab lunch or whatever the case might be, drop off some flyers. And then that's kind of your in, into the hospital system. we are purely like a boots on the ground kind of marketing, getting out in the community. we've used services for like lead generation and things like that. ⁓ I think sometimes those can be good and other times, you know, it's purely transactional. A of people are, I always equate it to like, if you're looking for, if you're genuinely curious and buying something and then.

all of sudden you get contacted by 10 different agencies. like, I didn't want all these people calling me. I just wanted that. I've been the person calling. So I, you know, I don't know if I enjoy doing that necessarily. I like getting out in person and meeting everybody and, and go into the local VFW and having lunch and chatting with veterans there, you know, going to a rehab facility in the area and talking to, talking to clients there, honestly,

you sometimes you just have to go straight to the client. So we'll go to, you know, section eight housing or whatever the case might be and leave some flyers there. that's been an easy way to get referrals as well as, figure out who some of the case managers in the area are. That's actually probably, that's one of our better strategies where it's, if it's a new area, you can look up, okay, what are some local, ⁓ maybe low income housing, typically on Medicaid, go there, drop some flyers, maybe get a call.

Maybe they're on Medicaid, so you can run their RID number in the system and you can figure out if they're on, if they have services, most of the time they don't, but it's worth continuing to contact them and stay in touch with them because then eventually if they do get services, one, you've developed that relationship with the client themselves, but two, you then end up figuring out who their service coordinator is and then you kind of weave your way through that whole dynamic.

Miriam Allred (56:13)
Mm-hmm.

Yeah. Okay, this might be a loaded question, but you still spend a good amount of time like documenting, managing the authorizations themselves. And I know this is a source of many headaches for many people. I just want to ask, are there any unlocks that you have discovered for yourself in managing this? Like any kind of tips, tricks, unlocks that you yourself have identified or developed?

Christian Sullivan (56:36)
Yes.

Yeah.

So we use HubSpot, which might be a little out of the ordinary in the home care industry, but we use HubSpot for tracking our entire sales pipeline, like our deal pipeline leads and everything like that. I like it a lot because it has a very like obvious contact to lead to, deal. call it, you know, referral, if you will. But

What it allows you to do is I've created in HubSpot specifically a referral tracking tool that has allowed me to just send automated reminders either to myself or whether it be a service coordinator or anything like that where we're actually just proactively reaching out. If nothing else, as far as like actual unlocks on like how to get the service, the authorization quicker, there's, you know, unfortunately I can't control how fast the other, the other people work.

But what I've noticed is, gentle nudges here and there. I'm like, Hey, you know, this person's services are coming up for renewal. always try and be as proactive as possible on that. So anywhere from 60 to 45 days out, I'm usually reaching out to the case coordinator, this whoever it is, to touch base with them about, are you guys going to get, are they getting renewed? Are they getting bumped in services or anything like that? ⁓ I, yeah, we make a ton of calls daily. So.

We try to be as proactive as possible on that. So I guess it's not necessarily like a huge unlock, but having something that allows you to track that stuff regularly, what their services are, all the, you know, general information that you need, Medicaid number, current services, current units that they have all that good stuff. And then when it expires, so that way you can set some automation, reminders to ourselves and, and again, send out automated emails based off that as well.

Miriam Allred (58:31)
Okay, that's what I going say. Something that can handle the nuances and then also attach a reminder notification to every single nuance, because like you said, the timeline is its own. But being able to stay on top of this proactively all the time, there has to be automated reminders.

Christian Sullivan (58:41)
Mm-hmm.

Yeah. One of the things that we've, we've started to do a little bit too, is, just scheduling like monthly check-ins with each service coordinator. cause what ends up happening a lot of times, it's not like one, it's not a one to one relationship. not, one client has one service coordinator, but it's not the reverse if that makes any sense. ⁓ so like I might have a bunch of clients, but they'll have the same service coordinator. it's, Hey, you know, Stacey, I would love to,

Miriam Allred (59:05)
Mm-hmm.

Christian Sullivan (59:13)
you know, block off maybe 30 minutes of your time, go through what's been going on with all of our clients. You know, these are the upcoming renewals that we have. are they going to get renewed? Like what's, know, are you working on that? What's that look like? ⁓ I think in this industry and, and, and it could be different state by state, but in Indiana specifically, everybody seems to be overworked at the, at the state level at the managed care entity level. So if you can do anything possible to

maybe take some of that workload off their plate by, you know, even if it is just a reminder, you know, they might not, they might not forget or they might not remember to do that. So if you can kind of bump it to top of mind, then usually it's like whatever's right in front of you, gets done. So I think just being proactive has been the biggest kind of unlock for making sure that that can happen.

And unfortunately I've seen the opposite side that where I'm not proactive and I just kind of assumed that the case manager's got it handled and all of a sudden it's three weeks and no anyway.

Miriam Allred (1:00:10)
Yeah, and then when you get that time with them trying to like brighten their day a little bit, I know that's cliche, but like you said, they're exhausted, overworked. And so if you do get that time with them, you know, like making a little bit lighthearted and enjoyable and trying to like lighten their day, lighten their load, but also like brighten their day at the same time.

Christian Sullivan (1:00:15)
Yeah.

Yeah.

Yeah.

Yeah, they're human too. They love to converse. And a lot of times when you're inundated with a ton of things that you got to be doing, a nice little five minute vent session might be what's needed. And a lot of times that usually goes a long way. Even if I don't say anything, it's just an ear to listen is sometimes the best, best sort of trick that you, that you have.

Miriam Allred (1:00:46)
Yeah, well, this has been super eye opening to me, honestly, Christian, like you are doing this day in and day out and it's intense and exhausting. know, talk about the people at the state level, like even you, you know, getting up and doing this every single day. But for the good of the clients, like I can I can feel that and sense that from you and everyone in this industry, like there has to be that heart and that passion or else none of this would be worth it at the end of the day. And I can I can sense that from you. guess my my last question is, like, despite all the challenges,

Christian Sullivan (1:00:57)
Mm-hmm.

Mm-hmm.

Miriam Allred (1:01:15)
and the day to day grind that you're on, like what keeps you grounded and motivated and moving forward.

Christian Sullivan (1:01:21)
Yeah. I mean, might not be a surprise, but you know, working with the clients, I think everybody can relate to it because everybody probably has grandparents or had grandparents at one point where, it sounds cliche, but like if you, if you kind of operate under that method or like thought process, it truly does kind of give you that extra little fire to, make things happen. and so, you know, I've, it's,

the conversation that you have with someone when you've been able to work through a hard situation with them and, and, you know, they end up better on the other side because of it. For instance, like if a clients, if we're going through NOA issues and we're trying to get services, what I've noticed a lot of times is a lot of our clients maybe don't have family that they're talking to on a regular basis. So you gotta put yourself in their shoes and they might be sitting in their house by themselves wondering what's going on. And if you think of it like that, you're like, I need to,

you know, kind of light a fire under my butt and get going. I need to figure out how to get this guy's services or this person, their services, because they're by themselves and over communication. I know I mentioned that earlier, but that piece of it too, is just calling to check in. You know, at the end of the day, they want to feel like you're their main, like they're your main priority. And I think if you operate like that, it's not possible to do that for every single person, especially as you grow. But if you do your best to try and make them feel like the priority,

⁓ I've seen, you know, bad relationships turn good real quick. ⁓ and so I think that is kind of the thing that keeps me going is knowing that there's, a true impact. talked about being coming from, from tech sales in the past and, and, at the end of the day, you don't, you don't land the deal, whatever they go home, everybody goes home. It is what it is. here it's, the day to day activity that I have has a major impact on someone's life and their wellbeing.

And so that is something that keeps me going on a day-to-day basis for sure.

Miriam Allred (1:03:08)
Yeah, wow, well said. This managed care model isn't going away anytime soon. And so you just have to kind of like grin and bear it. I guess I'm just curious where your head's at for this year. What are you going to double down on? Where are you going to try and improve in this chaotic model?

Christian Sullivan (1:03:14)
Unfortunately not.

Yeah. it's a great question. ⁓ and one that I, frankly, I don't think about a whole lot. I think, you show up on a day to day basis and you know, if you think about it as like a board game, if the rules change, the objective doesn't, it's just how you get to the objective. And I, and at the end of the day, like if, if my objective is making sure that all of our clients get the best care,

If the rules change, now it's on me to figure out how to make sure that they can continue to get the best care. So as much as it is a pain for me, I feel like I'm someone that can bear that burden for the sake of making sure that our clients are getting the best services. And I don't want to sound like some sort of sacrificial hero by any stretch of the imagination, but like, I don't know. I try not to think about it too much because it can be daunting and overwhelming. know,

I drive about an hour or so into the office every day. So I get a lot of time to decompress after at the end of the day. And a lot of those are some dark thoughts about all the things that went wrong. But the good news is the next day I get an hour to get ready to come into the office and all that goes out the window. Cause there's, you know, a service that I'm, I'm people are relying on me to provide, ⁓ not me going out to the homes, but relying on me to coordinate more or less. So that's, that's kind of what, my head's at. And

You know, whatever is going to change is going to change. It's not the first time. It won't be the last. So it's just not me to be flexible and figure out how we're going to operate moving forward.

Miriam Allred (1:04:53)
I really like that. The objective doesn't change, even if the rules do. Like, that's a really good motto to live by. That was well said. Well, Christian, thank you for joining me in the lab and being open and transparent and vulnerable. Like, know this, it almost feels like there's been like a heaviness to the conversation, but I think that's the reality of like what you're up against. And so I feel like you've done a great job answering these questions like openly, honestly, and people have kind of like a look into what this is like. And also for other Medicaid providers out there listening to this, like we have to lean on each other, you know.

Christian Sullivan (1:04:57)
Yeah.

Thanks.

Yeah.

Miriam Allred (1:05:22)
We have to not be doing this difficult work in silos, but reaching out to other providers, picking each other's brains, lifting each other up, even despite the heaviness. So thank you for being an example of that, Christian.

Christian Sullivan (1:05:32)
Mm-hmm.

Yeah, I appreciate you having me on. It's been a blast.