Miriam Allred (00:00)
Hey everyone, welcome back to the Home Care Strategy Lab. I'm your host, Miriam Allred. It's great to be back with you. Today in the lab, I am joined by Ethan Gurrieri, the VP of Operations of Preferred Care at Home. Ethan, welcome to the lab.

Ethan Guerrieri (00:15)
Happy to be here. Thank you

Miriam Allred (00:17)
Everyone should be watching this on YouTube because Ethan's setup is better than mine. He's a podcast, want to be over there. Just kidding. They do a ton of training for their franchise system and so they've got a great setup, which is awesome. So you're walking the walk and talking the talk today, Ethan. Let's start with your introduction. You might be a new face to many people listening to this and watching this. So let's start with kind of your personal background and your foray into home care.

Ethan Guerrieri (00:21)
No, just different, just different.

END

Sweet, happy to be here.

Yeah, so I introduce myself as third generation home care. It was actually my grandmother, mother and father who started back in senior care in 1984 in Daytona Beach, Florida. I don't know if this detail matters, but it was actually like in the garage with carpet, my dad always says, which I think makes it nicer, their first office. fast forward over 30 years later.

We started the franchise system in 2007, and then here we are today, a national franchise system, Preferred Care at Home can be found in about 20 different states, 60 individual owners, about 130 location units, Preferred Care at Home has, so yeah.

Miriam Allred (01:33)
Awesome. I always ask people like you that grew up with parents doing this. Do you feel like you understood what they were doing? Like in your teenage years, do feel like you understood what was going on or you are more just like a bystander?

Ethan Guerrieri (01:44)
Yeah, funny enough, growing up, my dad is ⁓ very Italian. He's got this white hair. ⁓ And growing up in Tennessee for part of my life, everyone thought he was in the mafia because he just was always around. ⁓ And they're like, your dad's always around. Who is this guy? ⁓ They must be, like the Guerrieri's must be in the mafia. And so part of me was like,

But maybe, but no, my whole life, ⁓ I always knew what my parents did just because my mother is a registered nurse. When you grow up in senior care, you hear the caregiver names and the client names and you visit the clients. So I always had an understanding of what senior home care was. And I would even be like with my dad, you should call Margaret. Maybe she could take the shift.

Miriam Allred (02:35)
Okay.

Ethan Guerrieri (02:37)
And I'll never forget one time I called out a caregiver and that shift was filled by that caregiver. So that was my first ⁓ filled shift ⁓ as a youngin.

Miriam Allred (02:46)
And you're like, wait, maybe I have a knack for this. I should get I should get involved.

Ethan Guerrieri (02:47)
Oh, exactly.

Well, truthfully, I always knew I wanted to do what my dad did. Always. Like, even as a young kid, you can ask any of my siblings. They all want to do different things. was like, home care is for me. I want to do home care.

Miriam Allred (03:03)
Interesting. So tell the story of you first getting involved. think this is super interesting. You're 19 and your dad kind of like tees you up for an opportunity. Explain what happened.

Ethan Guerrieri (03:13)
Yeah, first I'm in college and just full transparency, I wasn't the greatest student back in the day. ⁓ my dad sat me down and had a real conversation and he said, either gonna take college seriously or I'm gonna give you an opportunity to open up your own location from scratch, zero clients, zero caregivers. And I know that at that moment that was really a once in a lifetime opportunity. So I said,

I will take that. I had no money. So I was like, I'm ready to finally make some money here and start this business. And so it was from that day, was 2015, I ⁓ was 19 years old, zero clients, like I said, zero caregivers and started my own agency in Boynton Beach, Florida. was from Boynton all the way to West Palm for those familiar with the South Florida market. And yeah.

I had all the same struggles that a lot of the new owners have. Luckily I had the benefit of the franchise systems home office right there for the support. But growing that location, putting systems in place, the call outs, using caregivers for the first time, I felt all those growing pains, especially early on.

Miriam Allred (04:28)
Two things you were also 19 which not to knock on age by any means but I'm sure being 19 was a hindrance and then also Florida is like ultra competitive in a home care sense where those two like additional battles you feel like you have to face your age and then also being in Florida

Ethan Guerrieri (04:46)
You know, one of the things with age is I feel like for the competition, the answer is absolutely. I mean, I'll say this here, our hourly rate in 2015 was $15.75 And I know you never compete by being the lowest in the area. We weren't the lowest in the area. It's just because that market is just so saturated. The price gets driven down. But I would say to answer your first question, age was, it surprised me.

of how little age played a factor. Like it actually surprised me. I was more in my own head about the age than family members and even referral sources were. So ⁓ no, the age thing really wasn't an issue for me, just in my own head.

Miriam Allred (05:32)
That's very cool. I guess because we're working with like an older population, oftentimes there's this like stigma of they want like a mature population talking to them, maybe selling to them, educating them, but sounds like that wasn't the case.

Ethan Guerrieri (05:43)
Well, I will say this,

for a lot, like, because we have new franchise owners coming in all the time, and some of them have home care experience, some of them don't. And, you know, for stuff that may seem to us like second nature about, putting in advanced directives and ADLs and IADLs, really just basic home care understanding is another language. And they go, how can you expect me to have this conversation with a family member? And, you know, I go back to, listen, if,

Miriam Allred (06:03)
Mm-hmm.

Ethan Guerrieri (06:11)
If I could sit in a family room at 19 years old and have the family look at me and say, we're going to entrust you with this, it's all about first having a strong process and following that process. And so that's what I did at an early age.

Miriam Allred (06:25)
Yeah. And so we're going to talk about today going after hospitals. Like that is a key opportunity that nearly every home care company wants to achieve at some point. Like in Florida, it's highly saturated, like a lot of other markets in the country. And so getting into a hospital, getting that first referral, building that trust, turning it into a longstanding relationship is something that everyone aspires to. I'm curious when you were just getting started,

Were you in that mindset? Like I need to break into a hospital out of the gate or my first year or my first two years. Like at what point were you like, this is an opportunity that I need to seek out.

Ethan Guerrieri (07:02)
Yeah, so my first, my claim to fame ⁓ is within just under 13 months, we build 1.3 million. And so all of those relationships came through referral marketing for me. I read a research from Activated Insights that, the acquisition rate from a referral from a ⁓ healthcare professional was like almost

almost like 80 % at that time versus like an online lead you're looking at like two to three. And maybe some people say they have higher, but I was struggling with it. And I was like, man, I would much rather develop relationships with individuals that see the need for our care on a daily basis, get them to trust me and know when I get that referral, it's almost a slam dunk because I've already gone through the vetting and family members trust those case managers and discharge planners. So I had really good education on like the top tier places to go. ⁓

And really, just like everybody else, the kind of back to basics program on getting in front of them, knowing that it's a long game of developing a relationship, that people want to refer to people they like. The problem was the number one place, and I really don't care what anyone says, the number one place to get into in home care is hospitals. They see the need for care, not on a weekly basis, not on a biweekly basis, but on a daily basis. They see individuals

daily that are getting discharged that could use home care. And we had, in obviously Palm Beach, Florida at the time, we had so many large hospitals there that we wanted to get into, I wanted to get into so badly, and I just could not get the lunch in. Or even if I did get the lunch in, I just couldn't figure out a way to connect. Like I would spend the money on the lunch-ins if I did get them, and then it just felt like, okay, it went well. I think it went well.

But then I would never get referrals to even show that Preferred Care at Home is the go-to choice when it came to care. And so I was struggling there with that.

Miriam Allred (09:06)
So looking

back now, what was the disconnect? Like what does it boil down to? What do feel like you were missing?

Ethan Guerrieri (09:12)
Yes, it's all about having a valued service that really talks to their major pain points. And here at Preferred Care at Home, like one of the things I always try to communicate to our franchisees is what you provide for a hospital is a resource. You are a resource for them. And I felt like for the longest time I was in there almost as like ⁓ a vendor selling a service.

and not somebody coming in there as a partner providing a resource. And so when I was able to switch my relationship and really my talking points from like what everyone else was kind of talking about, care and making sure somebody stays at home and safely and quote unquote reduces readmissions, which we're gonna talk about today, ⁓ which is like a tagline that every home care owner says, but maybe doesn't know about.

That key word right there, readmissions, is really what changed the game for me. Diving into that.

Miriam Allred (10:12)
Okay, so let's you're prefacing this program that Preferred Care at Home has built and utilizes like across the system. Let's talk about that because I think this is super fascinating. There was a study that came out that identified the six primary preventative gaps to reduce readmissions. And this is like so meaty and so good. And your team is literally like put it together, organize it. And you are so graciously like about to share exactly what this is. And there's like so many nuggets in here that we're going to hit on.

That every single home care company listening to this can go out and replicate a version of this themselves and take this out to discharge planners at hospitals and educate them. love what you just said a second ago of like, felt like a vendor selling like a service, but then you became a partner that was giving away education. And that mindset shift is so important. And so you have to like offer them something of value. You have to like give them something that they don't know that will help them do their job better. And to me, that's exactly what this program does. So.

As we get into it, talk a little bit about the research that was done and some of the key points about just where the research came from, who they were targeting, and what the program has turned into.

Ethan Guerrieri (11:20)
Yeah,

yeah, So it was actually my mother back in, I think it was 2013 or 14, was the one who looked into this and developed the program called Smooth Transition Care, which we're gonna be talking about here. And this was back in 2014 where there's no AI, there's no Gemini, there's no chat. So she's actually reading these reports. So I'll take you back. 2010, the Obama administration,

during the Affordable Care Act put together a research team. That research team is the Community-Based Transition Program, I'll probably be using this abbreviation, CCTP. They gave them $500 million for research and pilot programs to really figure out what's going on with these readmissions. So just big fact, what we're dealing with today.

Medicare spends the most cited number that we see is about $26 billion annually on readmissions. Now, not all readmissions is preventable. Like sometimes people, seniors need to end up back into the hospital. What they were looking at during this research is the preventable readmissions. So the question, follow up question to me should be like, okay, so 26 billion annually on readmissions in this past fiscal year, what was preventable? What was deemed preventable?

Well, 17 billion of that is. So we're talking over 60 % of hospital readmissions is deemed preventable. So during this research, what they wanted to look into giving these agencies and these pilot programs that $500 million was to do some research, put together programs to find out what are the top reasons seniors are ending up back into the hospital within that 30 day window, because that's what a readmission is.

Once you get discharged, if you're back into the hospital within 30 days, that's considered a readmission. so, yeah, Jodi, my mother, looked into this research and developed what we call an evidence-based transition program, because we're looking into their data, what they published, and we're creating a program that comes alongside of that data to reduce readmissions. And studies show programs like this do reduce readmissions.

Miriam Allred (13:42)
Yeah, super, super interesting. To be honest, this was the first I think I've heard of this specific study. I feel like there's a good amount of studies, but this one, like kudos to your mom for identifying it and reading and researching, but then also like doing something about it. So I'm on the edge of my seat of like, okay, what are the six gaps? Because I think that's what everyone wants to know. Like what are the six preventable gaps?

Ethan Guerrieri (14:03)
Yeah.

Well, it just gets better for home care. like the, one of the things, Miram, when you talked about it, you asked me, this something that you're willing to share with everybody? And I just believe ⁓ home care needs a seat at the hospital table. Because once we start looking at these gaps, it's gonna sound like, I say, this sounds like Preferred Care at Home propaganda, because these six reasons, you're gonna see, this is because this is home care.

this is why these individuals are ending back up into the hospitals because home care is not in place. We do these things. And so briefly, I'll kind of walk you through these first, the six main reasons and then we can probably discuss there. So one, what they identified was when seniors are getting discharged from the hospital, they're given their discharge orders and a doctor comes in and it says, or a discharging nurse will come in and provide them

their documentation, here's your medication, this is what you need to pick it up, make sure you don't eat this, eat this, your follow-up with your specialist on this date, and they give them a packet, and then they essentially roll them out. I'll tell you firsthand, that wasn't real for me until I got one of my tooth pulled, and I'm coming out of local anesthesia, and I'm being told my discharge orders as if I can retain them.

And I'm sitting there and I have no idea. And we finally get into the car and we're driving and I'm like, when can I eat? When can I eat? medication? Luckily my wife was there. But this is the exact situation that we're finding seniors in. Is they're being told their discharge plans and their discharge orders and they're not able to retain that information because they're on all the new types of medication. They've been in the hospital for we don't know how long. They're on a different nutrition plan.

and we expect them to get their new care plan in place and put it in place. And so that just doesn't happen. And so there's a breakdown of communication during discharge. That's one of the main reasons. And so to break this down, there's really two clinical and four that happen at home, which are the reasons why seniors end up back in the hospital. And so that's the first clinical one. The second clinical one would be seniors don't feel empowered to take advantage and control of their own care.

So essentially, one of the ideas is they feel like all their care needs are in like this cloud that everyone has access to. And they just feel like, well, that specialist knows what this specialist knows, what that case manager, that hospital knows. And the answer is they're just not that. There's no concise information being shared. And because there isn't that, seniors don't feel like they can even advocate for themselves.

And so we're seeing a breakdown of even seniors feeling like they can take control of their care needs. So those are the two that are happening in clinical. The rest really happen at home. And so the third would be medication mismanagement. We've all seen it. We've walked into a home. We've done the assessments, medication everywhere, dining room table full of medication dating back to 2003. They're being prescribed new medication from the hospital.

They may be picking it up, may not be. Let's say they do pick it up. They may be combining old medication with new medication. It's a mess. And it's actually the number two reason why seniors end up back in the hospital is because of medication mismanagement. ⁓ Four, doctor's ⁓ appointments. They're not following up with their primary care or their specialists. So of course, I mean, it kind of goes back to one, if you think about it. They got those appointments lined up. It's not being retained or they're not following up with the necessary follow-ups. ⁓

Five is fall prevention. So here are some things that I would like our owners to also think about. Fall prevention is yes, a 52 checklist of making sure non-slip rugs are out and cords are out. But what I always used to tell case managers is as much as is making the home a safe environment, what I want you to know is when our clients and your patients get discharged and they're at home and now they're the ones getting up and

using the restroom and taking a bath and then getting dressed and then going and preparing their meals. There is a tax that happens on the body so that later in the day when we go to do the mundane things, we're more frail. so falls, yes, is a safety checklist, but it's also being there, especially early on, to help them with those activities so later in the day the likelihood of a fall decreases. And then,

⁓ The sixth and final reason according to this research why seniors ended back in the hospital is lack of chronic illness and education so they found out that seniors are Calling 9-1-1 when they're forgetting to take their medication and it's in its pain. You have you have a bruised hip. That's why you're in pain. Did you take your medication? Okay, we'll do that

They're calling 911 when they should be calling home health. And so there's a lack of education on the resources that are in there and seniors panic. And when they panic, what we do is we call 911. And so these are the top six reasons why ⁓ seniors will end up back in the hospital for a readmission.

Miriam Allred (19:29)
⁓

Amazing. And like you said, it feels like home care propaganda, like obvious to us that we solve these things, but it might not be that obvious to the, to the discharge planners, to the case managers. And that's my question. When you went out and you had, luckily you had this knowledge at the beginning, like we're giving this knowledge to people, but you had this knowledge at the beginning. When you went out and took this information to these hospital leaders, to the discharge planners, and you explained it to them in this framing.

Did they connect the dots that this is a perfect fit for home care or what is their reaction when you're explaining this to them?

Ethan Guerrieri (20:04)
Yeah, so first, the answer to your question is absolutely it's not obvious to case managers. It's not. It's ⁓ problem that they have and they're aware of it because hospitals are getting penalized for high readmission rates, but it's not something that they understand why. So when we're sitting here and educating them on why seniors are ending up back in the hospital, and when you refer to me, these are things that we're gonna take care of, and then like we're gonna talk about later, and here's the best part.

here's a unique package that every single one of your individuals that are high readmission rate can utilize. ⁓ It's a slam dunk and that's how we started ultimately being there. So yes, to answer your question, you have to go in there with the heart and the mind of education. Never assume that they're aware of these, because they're not, they're just not. And so you're putting together this presentation as an education package.

Miriam Allred (20:57)
Yeah, their focus is the client in the hospital, not the client going home from the hospital. But you come in and share with them, okay, one in five Medicare patients discharged from the hospital will be re-emitted in 30 days. Your patient right here today will be back here in 30 days if we don't do these preventable things. And that's just such a mindset shift for them because again, they're not thinking like that, but you help them think that way. And then it immediately puts you in this like trusted resource partner category of like, wow, he just...

told me something I didn't know that will help my patient not be back here in 30 days. And we should actually do something about that.

Ethan Guerrieri (21:32)
You got it. Yeah, spot on.

Miriam Allred (21:35)
So, so, so interesting. Okay. So, like you said, hospitals are so hard to break into and it takes months to do so. But I think part of the issue is home care leaders, salespeople, business development, like they're going in and making the same pitch that they're probably making with skilled nursing facilities and assisted living. Like it's too generic. The only way to

get into a hospital is to speak their same language and address their immediate pain points. Would you agree with that?

Ethan Guerrieri (21:59)
Hmm. Yeah.

Well, so I would say this, and I mentioned earlier for home care, like you may have gone to like a home care marketing guru or just heard something on a podcast about, this kind of topic that we're talking about. And they use the word readmissions as like, it's almost like a tagline at the end of the service that you provide. Right? Like that's how, if you think about it, Miriam, right? It's kind of how we hear readmissions. we help reduce readmissions.

Well, how? How do you help reduce readmissions? What do you have, do you understand the readmission issue? And so this is what this program allows you to do for a hospital. It allows you to sit in that biggest pain point a hospital has and say, I'm not just gonna throw this as a tagline at the end of the services I provide. What I'm gonna do is I'm gonna create a program around that so my services come around your biggest pain point. And I'm gonna showcase a,

here are the reasons why seniors are ending up in the hospital within 30 days, and here are how our services come around that and provide a solution to that. And so I couldn't agree more with what you're saying is it's not just about coming in there, communicating your services as if you were to a hospice, because those talking points are different. They don't care about readmissions. That's not what hospice cares about. And so what we do in home care, unfortunately, lot of the time is we communicate our services

the same to all our different referral marketing partners. And we miss out on the complete joy and opportunity to really come alongside our healthcare partners and provide in their absence. And you know who the biggest beneficiary of these type of programs are? Not the home care provider, it's the patients, it's our clients. They're the ones who ultimately win when home care providers are aligned and coming alongside and communicating what we offer in a way

that addresses key pain points.

Miriam Allred (23:57)
Yeah. Something interesting you said a minute ago is that hospitals get fined for readmissions. That's super interesting and I don't know a whole lot about that, but can you explain a little bit more? They track readmissions at the hospital in general and then the government finds them or like explain what happens there.

Ethan Guerrieri (24:13)
Yeah, so it's

CMS. So yes, the answer is you today could go on healthfinder.gov and look up your local hospital and its public record. You'll be able to see what their readmission rate is. I think the federal government allows or Medicare allows a readmission rate of roughly 15%. If it's higher than that national average of 15 %

they're going to be fined a percentage point up to 3%. So 3 % of their Medicare reimbursement can be fined. We're talking about hospitals that work on 1 to 1.2 % margins. So when we start getting fined 3 % on our Medicare, which is our highest paying insurance, and it makes up for most hospitals 40 to 60 % of our total revenue, when we start getting fined on that, we're talking about

tens of millions of dollars that hospitals, a single hospital could be getting fined. So you're gonna see a hospital that has a higher readmission rate than 15%, which you can look up, ⁓ being fined anywhere from 0.1 % to all the way up to 3 % of their Medicare billing.

Miriam Allred (25:24)
And back to educating the discharge planner. Do you think the discharge planners know this and understand this?

Ethan Guerrieri (25:29)
Of of

course, absolutely. The answer is absolutely because it's a discharge. So for a hospital, it's called a case manager. So case management, is their job to discharge and discharge safely. They're the ones who are putting the resources together for their discharging patients, whether it's going to a skilled nursing facility because they had, you know, they've been in hospital for three nights, triggered 20 days in a skilled nursing facility.

Whether it be that, whether it going home with home health, whether it be setting up DME in the home, they're the ones in charge of making sure this individual is sent to a place and set up for success. So they are very well aware of their readmission rates. And so we talked about the CCTP, which is the $500 million research, which was really nice, right? It's like, oh, this is great. 500 million, you're gonna find us resources, the reasons why. And that was the idea of it.

But now what hospitals have is they have the Hospital Readmission Reduction Program, the HRRP. Think of the first one as the carrot, think of this one as the stick, right? So the HRRP now is over the hospitals monitoring their readmission rate and they're the ones who are assessing the penalties. So they are very well aware of the Hospital Readmission Reduction Program. Very well aware, they're the ones who are sending out the fines.

Miriam Allred (26:52)
And like you just said though, that these case managers, they're quick to send referrals to SNFs and rehabs, et cetera. Home care may or may not be on their radar, but then this is where, okay, then we educate them on the six preventable gaps. Home care can address each of those. Home care is now a good player and a good option to send these people home to avoid the readmission.

Ethan Guerrieri (27:17)
Yeah. So home care is never meant to replace a benefit that they already have. It always comes alongside and provides in its absence. So that's like, that's a free talking point for anyone here listening. Our program is never to replace. It's always to come alongside and provide in its absence. The idea is where do we fit in and all the different stops? So for example, if someone's been admitted to a hospital three days, they're gonna go to a skilled nursing facility unless

the AMA and want to go home immediately, which we see all the time. It's where we get a lot of our larger clients. For hospitals though, what we see on a consistent basis is individuals being either gone through the ER and being sent home same day happens all the time, happens every day. Okay, those individuals probably should be sent home with some help or they've been admitted for a day, maybe two, and then they're going home because the triggered in its set of three nights

to go into a fully paid for Medicare bed at a skilled nursing facility. So these are the type of individuals that we're probably looking at for a hospital for this is anywhere under three days at a hospital being sent home. Most of the time, not all the time, but let's just say most of the time, if they've been admitted to the hospital for more than three nights, they're gonna go to a skilled nursing facility. But yeah, you hit it on the head, which is the biggest, I think, obstacle

home care owners face is how do I break through a case manager's mindset, which is just referring Medicare benefit or state benefit options to my, their patients, our clients? Because we're not that for the most part. We're not the state benefit. So how do I get in there and work my way in? And so this program opens the door, but what else can we tie this to to make it a no brainer refer? Because

Okay, so I just say this and then say, and we do home care? Where's the next step, right? And so you gotta put together a little bit of a transition program, which I'm sure we'll talk about.

Miriam Allred (29:20)
Let's get, let's get right into it because like you identified, there's these six gaps. There's two, the clinical four at home. I'll actually want to start with the clinical, which is like you said at discharge, there's just like, opened the floodgates of information and the client and the family is just overwhelmed. Like we're coming off of a surgery or an incident or like a stressful moment in time. And now we're dumped on all this information. Now we got to go home and remember all of this. Like, let's talk about that piece specifically first, how in the program that you've built, how are you addressing.

that first clinical piece.

Ethan Guerrieri (29:52)
Yeah, so let me add to this is how many times do the seniors know that they're being discharged until two hours before? Not many. They may be aware that it's happening today. Maybe it's not happening today, but a lot of the time it's just, know, ⁓ I'm being discharged. ⁓ okay. And this isn't just a normal nurse coming in to make sure I take my medication. It's somebody giving my discharge orders, right?

We have this utopian view of what these discharges look like, and it's just not real. And this is why we're finding breakdowns in the readmission rate. so, yeah, having somebody there, and it used to always be me because it was my opportunity to handle that referral, sit with the case manager, understand the order, put together a care plan for my caregiver, and then I would hand off that care plan to my caregiver.

So that transition coach was always me in the rare case. I couldn't do it. I had my ⁓ client service director out there handling that. But I loved as the marketer to be the one being the transition coach. Because you know what, Miriam, it allowed me to sit in my case manager's office at her chair, hang out with her, talk with her while I'm putting together the transition plan. So.

Miriam Allred (31:12)
And you

call it transition coach, which that's the, is that the term you use internally and externally? You call yourself a transition coach, which I like because that's the whole concept is like, we're about to help transition you. We are kind of like, I almost think of like a doula. It's like, we're kind of this like third party person in the room that understands what's going on and we are going to be the coach through this.

Ethan Guerrieri (31:17)
Yes, correct.

Yeah, well you got it. And my whole thing was like, will always, when you call Preferred Care at Home, I will always make your job easier, always. So you have someone who's at risk, I'm gonna come in here and I'm gonna take it from there. I got it. Just give me the reports, give me all the documentation, and I'm gonna put together the Smooth Transition Care Program to get this person back home, identifying these six main issues and putting them to rest, right? Making sure those things don't happen. So you got it.

Miriam Allred (32:01)
So you said you're in the room and you're taking notes or like putting together a document. think you said like a care plan for the caregiver. I also understand in your program, there's like this personal health record. Are those two separate things or is that part of what this document is?

Ethan Guerrieri (32:12)
Yeah, yeah, absolutely. Yeah,

yeah, so it goes to the point number two, which is the clinical side, right? We talked about the transition coach, which I was, and then we talked about the lack of empowerment. According to the CCTP, they said, seniors don't feel empowered to take control of their own care. And so what we wanted to do for all of our smooth transition care clients, we wanted to make sure they had a tangible, identifiable,

personal health record that they could take to all their either specialists or primary care physicians so they understood exactly what's going on. And so we put together, I think it's a 15 piece toolkit that really identified all the chronic illnesses, what's acute illnesses that are going on and the care plan that's been set in place so that when they go to their specialist or their primary, they knew what was going on and they could bring that personal health record to be able to answer maybe questions.

that their PCP wasn't aware of.

Miriam Allred (33:11)
So one distinction here, do you, there's like, it's like a templatized document, essentially, do you fill that out for them or you give them the template and the client and the family actually fill it out or do you fill it out?

Ethan Guerrieri (33:20)
⁓ yeah, no,

yeah, we have to fill that out. Absolutely. Yeah, so that's, I mean, that's what I'm sitting in the room doing is putting together that 15-piece toolkit. So that is something that we give to all of our smooth transition clients, that 15-piece toolkit.

Miriam Allred (33:39)
And why doesn't this exist? When I hear you saying this, I'm like, this just feels like a no brainer to me. Like every, every company should be doing a version of this because there's so much information. No, not very many people would like do this on their own, like put something together and then have it prepared to take to all of their specialist visits. Like you were doing this for them. Every company should be doing this. And why aren't they? I guess is my question to you.

Ethan Guerrieri (34:02)
I think maybe awareness of the pain points would probably be one of them. I hope when people in healthcare and home care listen to this, they're made aware of a pain point that a senior has and now they can create solutions to that. And so that's what, you know, my mother looking to this research, she was able to do. She was able to find out the major pain points and then we were able to create solutions to that. So I think the first is just a lack of education. Home care has never been invited to the table.

for Medicare, right? It hasn't been. And so we're often looked at as like a luxury item that most of their patients quote unquote can't afford. And so because of that, we just don't look into the government funded research that is out there. And so that's what this program did.

Miriam Allred (34:53)
So then you put together that document. Is the document ready when you're leaving the hospital or you kind of take it back, like refine it, finish it. And then do you take it to like the in-home assessment or the first visit assessment? Like, I know this is like in the weeds, but I'm just so curious. You put together that document, where does it go? And like, what is the next step?

Ethan Guerrieri (35:09)
Sure. So it's tangible,

it's a physical document. going back to the mindset that we have is how can we change the fact that seniors don't feel empowered to take control of their own care? How do we change that? Our solution was we need to give them something not in the cloud, because everything's in the cloud, not saying it's wrong. We're very tech forward here, but we wanted to give them something extremely tangible that they can feel, they can read.

that's physical that they can take to their specialist and have for them. Whether they use it or not, I don't know, but we're gonna give it to them that's physical. So yeah, it would be either printed at the hospital or I would go back to the office, print it, and then drop it off for the family. So it's a physical document that we would prepare for them and it would be all filled out and then we'd give it to them.

Miriam Allred (35:54)
Okay.

Yeah. Yeah. Which is a small detail, but super important. know, you and I, it's like, I should have that in an app and then I can show that to my provider, but they want the physical copy. They want it in the Manila folder. And I guess you said, we don't know if they're using it or not, but I hope they would be like, they're going to their next appointment. And it's like, rather than recall all this information and all the medications, it's like, take this pamphlet that has it all handed to the provider and then start the, the consult right then and there. Like, I think it's just so valuable to have all that information packaged up.

Ethan Guerrieri (36:12)
You got it.

Miriam Allred (36:30)
in their hand to take. So then what comes next? So the transition coach is there. You yourself are there in that moment. You go through that whole kind of discharge plan. put together the document. what's the, what's the role of the transition coach thereafter? Obviously there's getting to the first shift. I'm imagining there's more communication and steps between here and first shift. Like, what does that look like?

Ethan Guerrieri (36:30)
Yeah. Yeah, exactly.

Yeah.

Yeah, so let me just kind of back up a little bit. There's probably many listeners here, if they don't have it, they need to create one. They'll have like a hospital to home package, very common in our industry. And that's what I always differentiated myself with. I used to always say, this isn't a hospital to home package. That's not what I'm doing. I'm providing an evidence-based solution to the readmission crisis. And so it just happens to be getting somebody from the hospital back to home and putting together layers.

to make sure that they remain at home safely. And so, you know, from here, really transitions to the caregiver now coming into play and providing that transition from the hospital back to home. But what we're doing is we had specialty caregivers that would know exactly how this transition program works.

They would have the 52 point checklist to be able to check off the home to make sure the home is a safe environment. Sometimes I would do that. Sometimes our ⁓ our client service director would do it. A lot of the times though our caregivers would follow that process and then they would be able to get that checklist back to us to make sure the home is safe. ⁓ Additionally, they would be given a transition booklet to be able to follow of the medication. So I'm there letting him know her. She's at CVS Pharmacy.

This is her prescriptions that need to be picked up. Sometimes a hospital would already have the medication filled out for them. Sometimes they didn't. And so we would make sure all the medication is good. A lot of the times we would get calls saying that the medication is all over the place. And then I would come in, I would help either partner with the home health that was in there to do a medication reconciliation, or we had a local pharmacist that we partnered with to make sure that happened. ⁓ But to answer your question, Miriam,

It is from the transition coach, it's a handoff to the caregiver to start the hospital to home process.

Miriam Allred (38:50)
But I like what you're saying in that the caregivers are trained on this program so that when the transition, the handoff occurs, the caregivers not like caught off guard of like they're using this phrase, you know, transition and readmission and hospital at home. Like that could catch a caregiver off guard because the client is expecting that now that you've been there and been a part of the process, the client and the family are kind of like expecting a service.

And it's important that the caregivers trained on that. So I imagine in-house training for the caregivers includes a lot of talk and education on this specific program. What does, what does that look like? It's just explaining this whole process to them, or is there more specific like curriculum around this?

Ethan Guerrieri (39:22)
Exactly.

It's

aligning the team on a shared objective. so adding your caregivers to understanding issues that home care solves is never a bad thing. And so them understanding the services and what they're doing for these particular clients make a big difference. And why they're doing that is the same type of education that we give to our case managers would be the same type of education we give to our clients who are caregivers.

who are ultimately gonna be our smooth transition caregivers.

Miriam Allred (40:00)
And to go back to what you said a second ago, A lot of agencies position as like a hospital to home. They use that term like hospital to home. You said, you know, your position is like this evidence-based readmission program. obviously evidence-based is a great like phrase to use, and this is evidence-based and you can back that up. Is hospital to home a disservice or like, is it, are you knocking on that?

Ethan Guerrieri (40:24)
No.

Miriam Allred (40:26)
Like should

agencies reconsider that phrase? I'm just curious because if a lot of people are using that, like should they be thinking differently?

Ethan Guerrieri (40:29)
So.

Yeah,

the answer would be I would. I would attach your program to something greater, ⁓ which would be something like this smooth transition. Just because what ends up happening with a hospital home, if you're not careful, you just become like another glorified Uber or even emergency ⁓ transporter. And that's never what we want it to be, ever, ever.

I always wanted to be considered an expert in helping hospitals reduce readmissions and then with that an expert in home care. And so if you're not careful, if you just market yourself as a hospital home, you're marketing yourself as a glorified Uber service. And so just be very wary of that because a lot of these listeners here, they provide the same services that Preferred Care at Home does. And so you have the opportunity to talk about these beautiful talking points and how home care can come alongside it.

And evidence-based, the reason why that terminology is so important to me personally is clinically, everything is about evidence. What is the evidence behind this program? Case managers and nurses love that. I'm not speaking hyperbole here, it's an important phrase. So yes, it's looking into the research, but greater than that is the studies show that by, ⁓ so let me look at here. So studies show by the,

archives of internal medicine that programs like this reduce readmissions by 30%. So this isn't just evidence on their research, but it's evidence that programs created just like this will reduce readmissions by 30%.

Miriam Allred (42:14)
Yeah, you and I are like sales and marketing people and verbiage and terminology really matters. And so that's why I asked you that question of like, you tell me like, should we be knocking on that? You're right. And that it could get lumped into something that it's not like home care services is so handheld and customized and tailored to the client and individual that if you just blanketly use hospital at home, you could get lumped into something that you're not. And that's really important for providers to hear.

Ethan Guerrieri (42:39)
Yeah, and I would say like the reception, like if I communicated this package and they were like, okay, so you're a hospital at home, I would be really upset with myself on how I communicated this, because I didn't do a good job, because it's so much more than that. I would want them to be like, we've never heard of something like this before.

Miriam Allred (42:58)
much more.

Mm-hmm. And I want it. Yeah. It's like they've

Ethan Guerrieri (43:03)
and

I have someone right now who could benefit from this. Or I wish you came in yesterday and told me about this. That's the response I was always looking for.

Miriam Allred (43:07)
Yeah, exactly.

Two quick detailed questions. Thinking about you being in that meeting as the transition coach that like you said, you were doing that. So oftentimes it's probably the sales rep, the business development person doing that. Do you charge for that as a service or that's, know,

Ethan Guerrieri (43:32)
Yeah, so

it's a one. So here's a beautiful, beautiful thing about the smooth transition care. It's a one time care package. How the listeners will create it can be different than the way we did it. But it was a one time transitional care package that can stem from what we've seen is, you know, hospital home one time or multiple days going to about that 72 hour mark where we see a significant

drop-offs or multiple check-ins throughout the day. So we create care packages and offer it to the hospitals as a one-time payment. A part of that is everything you get here. And that price point would be at a rate that is a no-brainer. And we've even seen hospitals pay for this transition program for their lower-income individuals who couldn't even afford the transition plan. So we were able to be reimbursed by the hospital. And so, yeah.

To answer your question, it is included and it's a one-time fee package that we offer at hospitals.

Miriam Allred (44:37)
And just to clarify, typically the family or the client would pay for it or more typically the hospital would pay for it or 50-50.

Ethan Guerrieri (44:46)
It's

absolutely both and you may be able to work out a relationship with a hospital that was even better than mine where it's mainly the hospital. A hospital readmission on average, you guys can use, will cost a hospital about $15,000. So a high risk individual being discharged, it makes sense for them to spend even if it's $1,000 on a transition program or a couple hundred to ensure the risk drops.

To answer your question for me, what I saw, mostly the family, but we did have hospitals reimburse for this.

Miriam Allred (45:22)
Oh, go on it. Okay. That's surprising to hear. I, I wouldn't have anticipated the hospitals paying for it, but if you position it like you just did, which a readmission can cost you upwards of $15,000 or more here, we're about to offer you program that can reduce this readmission guaranteed by like 30 % at this price point. They should be receptive to that. What about positioning it to the families? I'd imagine you position it as

Ethan Guerrieri (45:40)
That's right. Exactly.

Miriam Allred (45:48)
It's the start of care. This is kind of like a, almost like a setup fee. That's maybe a weird way of putting it, but it's like, this is the package where we get started. And then this turns into hourly care, et cetera. Like, do you kind of like bundle it into like a larger package or, and, or would you ever sell it as like a one-off to the family? Or that doesn't really make sense.

Ethan Guerrieri (46:05)
Yeah, so the thing is, truthfully, when I got a referral for the Smooth Transition, it was much different than really any other referral. It's almost a done deal. They're getting discharged and they need help essentially getting home and staying there safely or being set up for success. So there wasn't any selling of that portion to the family. From there, we would sit down and say, this is the package. Would you like to continue services after? was a lot of the conversations.

And just frankly speaking to lot of your listeners here, the individuals who are at the highest risk of readmissions are those who are socially and economically disadvantaged. And the odds of them being able to afford long-term care consistently was minimum. We probably saw anywhere from 10 % retainer on smooth transition clients. Now,

Most of them needed it, but they just didn't ultimately have the resources to keep it. What this program did though, is it opened the floodgates for all the other private paying referrals. There was no other home care company in there the same way that Preferred Care Home was because of these programs. There's no one developing relationships with these case managers and they knew exactly what I did and they knew that this wasn't something that was gonna provide long-term.

So whenever they had individuals that needed care, which was frequent, which is one of reasons we were able to grow so quickly, was sent to me immediately. And so that's what this program essentially sets you up for.

Miriam Allred (47:44)
And arguably this is how you prove your value. You take care of their most vulnerable census, their most vulnerable population. Therefore, when you get the maybe more capable affluent clients referrals, they're different demographic. And so therefore you, you know, it may be a little bit easier to take care of them in different ways, but you prove your value to the hospital by developing this program and helping their population that needs it most.

Ethan Guerrieri (47:47)
Exactly.

Yeah,

yeah. And the referrals, once you develop these type of relationships with these case managers, when you do get these type of referrals, I mean, it's a slam dunk. It's a slam dunk.

Miriam Allred (48:24)
So this is to kind of just like bring it full circle. This is what you use personally to have so much success in such a short period of time. Now this program is rolled out across all of your franchise systems. I might be putting on the spot with this, but any other like success stories that you can think of of families or hospitals that you or others have been able to break into and really saturated markets like based off this program, any other just like success stories you can think of.

Ethan Guerrieri (48:47)
⁓

Yeah, of course. This is something that is national for Preferred Care at Home Smooth Transition Care. It's on our website. It's one of the things that in training we ingrain into our owners as a program to use for hospitals and for skilled nursing facilities, which I do think would be advantageous for us to talk about for a little bit, as a key way to differentiate yourself from really the competition. ⁓

To answer your question, yes, daily we see success stories from this new transition care.

Miriam Allred (49:22)
Yeah, yeah. You mentioned using this for SNFs, skilled nursing facilities as well. Is a lot of what we've talked about similar? What would be some of the key differences positioning this to SNFs?

Ethan Guerrieri (49:31)
Yeah,

the talking point for a hospital in a skilled nursing facility is almost identical. It's just for a sniff, it's almost double jeopardy. Not only are they getting fined, ⁓ their fine is up to 2%, but they are also, if they have a high readmission rate, like we talked about, their main referral source is a hospital for their high paying Medicare dollar, you know, traditional Medicare.

three nights in a hospital trigger the 20 days at a skilled nursing facility. And so if a hospital refers to a skilled nursing facility and they have high readmission rates, they're gonna go somewhere else with those higher paying and then maybe give that skilled nursing facility the lower paying advantage plans, right? And so they want to keep individuals, their patients home and home safely because not only are they getting penalized, but also

they could be hurting their top referral sources with these hospitals. And so this talking point works amazing for case managers at a hospital, but in my opinion, actually probably works better at a skilled nursing facility with discharge planners because like I said, now we're dealing with double jeopardy.

Miriam Allred (50:46)
And do feel like it's all part of one kind of like comprehensive process and that the hospital referring to the skilled nursing facility, develop relationships with both and there's referrals kind of flowing around all three of you. Like, do you feel like it's all kind of one comprehensive relationship and process or it's, it's very much like there's the hospital relationship and there's this sniff relationship and they're two different things. Okay.

Ethan Guerrieri (51:08)
it's definitely that second. You

have a relationship with case management. See, once that handoff's done, that case manager, that bed's been filled with somebody else. And now they're coordinating another discharge plan, right? And so that case manager's constantly discharging, right? Admitting through the ER, then discharging with resources. So they're not, when they discharge and handoff, they expect the next continuum to take care of that, right? So that handoff,

that relationship is completely unique. And so you gotta be able to develop that as well. ⁓ And so yeah, there's not so much synergy there that we probably like, it would help, I would say. ⁓ But we can bridge that gap. And one of the things I will say is, ⁓ so HRRP, which is the Hospital Re-Emission Reduction Program, that's the penalty, that acts as the stick, that monitors the readmission for hospitals.

Skilled nursing facilities have something called value-based purchase. So essentially Medicare's asking, is what we're buying, like we're paying for the care for this individual, is it valuable? you doing what you're saying by getting them better and getting them home safely? If it is, you get your full reimbursement. If it's not, then we're gonna start deducting that reimbursement up to 2%. So they're also getting penalized.

we're seeing a higher readmission rate from skilled nursing facilities roughly at 20 to 25%. So, higher than hospital, which is 15. Because individuals that are going through that continuum, right, from a hospital to a skilled nursing facility probably have more serious issues because they've stayed longer. So the readmission risk is higher. So, also, lastly, what we're dealing with is at a skilled nursing facility,

You get your payments, the longer that individual stays, the less you start to receive from Medicare. So you get 20 days fully paid for by Medicare. So it's a PDPM, Patient Driven Payment Model. So the idea is, hey, get this person better quicker. And as it takes longer, we're gonna start reimbursing less for certain services. And so for a skilled nursing facility, if their beds are full, and we have Nancy on day 10,

but we have somebody who a hospital needs to discharge, I can get more for that new patient if I can get Nancy out. Does that make sense? So we're seeing like, I mean, just running a business, the pain points that skilled nursing facilities are ultimately facing. And so this program for some, individuals in that situation for skilled nursing facilities just makes sense to them. Just makes sense.

Miriam Allred (53:36)
Mm-hmm. Mm-hmm. Mm-hmm.

And home care is the glue. know, my like naive mind is like, there's all these post-acute partners and they're sending referrals and they're interacting. like the reality is, you know, like the reality check for me is like, they're focused on what's right in front of them. They're not thinking about tomorrow. They're not thinking about this client in seven days from now. They are focused on putting out the fire in front of them. But home care deals with all of these players and has relationships with all of these players and, is the transition.

position player for the client throughout all of this. And so that is what I, that is what we should be focusing on is making yourself the glue tying all of these partners together. So, and, and all from the position of the client, like what's best for the client is they need support across this continuum because all of these continuum players are not focused on the longevity of the client, essentially.

Ethan Guerrieri (54:29)
That's right. That's right.

You got it.

Got it.

That's it. It's advocacy at its best, right? Understanding the needs, being able to put together a package, looking into the data. I mean, they spent a lot of money on this data, so we don't need to do it. Looking into that and then being able to communicate at a high level saying, hey, listen, I deserve a seat here and here's why. Here's why I deserve a seat. Let me educate you on the main reasons and let me show you that home care is the solution to this.

Miriam Allred (55:15)
Mm-hmm.

Ethan Guerrieri (55:15)
I

always say, I always say, listen, this sounds like, and I said earlier, this sounds like Preferred Care at Home propaganda, but this is your research that I'm just reading back to you.

Miriam Allred (55:26)
and offering up solutions, because a lot of people will consume this information, but it's like, what do we do with this? You have built a program and are offering the real like tangible solutions that impact the results, which is fines and fees and high readmission rates. Like there's all of these numbers, but it's like, what do we actually do about that? And how do we position this as an actual solution?

Ethan Guerrieri (55:46)
Exactly.

Miriam Allred (55:47)
This is so awesome. Ethan, you're an all star. This is so, so good. Again, like you're, you're maybe one of the more like under wraps franchises in the system, like a little bit smaller, but look at you guys building programs like this that are changing the game for your franchisees out in all of these markets. Like this is what it's about. And we're in this era of differentiation. Like home care is getting saturated everywhere. Like, yes, there is enough demand to go around. That's what everybody says. Like there's clients to go around.

but developing relationships with hospitals, SNFs, some of these competitive players in every market, you have to stand out. You have to offer up a program that's unlike anyone else's. And to me, this is like, this is the program. This is what you have to build for yourself, train your people on it, go out and deliver it. And that's what you guys have done.

Ethan Guerrieri (56:38)
Sweet. Thank you. I'll tell, I'll let my mom know about that. She'll love that.

Miriam Allred (56:41)
Tell your mom that she's like a pioneer in this space and and look what you are third generation home care owner sharing all of this information with hundreds if not thousands of home care operators around the country. Like this is what it's all about. This is what I am trying to accomplish is just like elevating and educating this entire industry. So we're all operating at a higher level so that home care continues to get a seat at the table in this post acute space. Like that is the goal.

Ethan Guerrieri (56:44)
Absolutely.

Love it. I do. And honestly, I feel like that's a job well done because that's the passion that should be brought into these facilities. Once you have that fire, that you have a solution to a problem, referral marketing changes. And that's if your listeners get one thing, that's it.

Miriam Allred (57:08)
I'm preaching to the choir. Do you feel the passion in my voice? I'm like preaching to you.

That's it. That's it. Well, Ethan, thank you so much for joining me in the lab. If we just talked through this program, what I would like to do is put all this information in the show notes for listeners to be able to kind of see what this looks like. But my call to action is develop this on your own. know, take the foundation here that Ethan has shared and that Preferred Care at Home is built, but make it your own. You know, turn this into something that you can go out and organically share and talk about as a business development rep or an operator of these companies like

Take this foundation, go out and build it on your own and then refine it with your own partners in your own market because yeah, there are nuances in every market.

Ethan Guerrieri (58:07)
Absolutely.

Miriam Allred (58:08)
Ethan, thank you. We'll go ahead and wrap here.

Ethan Guerrieri (58:11)
Thanks for having me.