Miriam Allred (00:01) Hey everyone, welcome back to the lab. This is Miriam Alred, your host. I am super excited for today's conversation. sitting across from Paula Marks, the VP of At Home Caregivers in California. Paula, welcome to the show. Paula Marks (00:15) Thank you so much, Miriam. I'm so grateful to be here, grateful for the opportunity. Miriam Allred (00:20) You're grateful and I'm grateful because this conversation is going to be fantastic. have interviewed a lot of people and I'm not usually particular in people prepping notes and coming super prepared, but you have. And normally I go super off script and ask you a bunch of random one-off questions that come up in real time. today I actually want to stick to the script to make sure we get through all of this great information. So thank you for coming prepared. Paula Marks (00:44) Thank you so much, yes. Miriam Allred (00:46) For those that don't know you, let's go ahead and start with your introduction. Tell us a little bit about yourself and your background getting to where you are today. Paula Marks (00:53) Thank you. Yeah, so that probably has to do with how prepared I am. I actually come from an academic background. So ⁓ I have a master's in sociology, actually criminology. And so I'm a systems thinker. And I've kind of used that and applied that to home care. ⁓ And I always am kind of over-prepared. I always get places at the first person to be there. And that's just kind of the way I think, because I don't want to miss saying anything really, really important. I got into home care first through being a business development person at a company called Visiting Angels. And Visiting Angels, as a lot of people know, is a national home care franchisor. And I ⁓ had the privilege of working with a franchisee that had three different offices serving the Bay Area. And I loved my employer. It was probably one of the best professional relationships I ever had. And I actually quoted her just a second ago. She said to me, Paula, You need to be specific to be terrific. And I really learned sort of how home care operates. And I kind of moved up in that ecosystem and it was a great. privilege for me to kind of have that education. And that brought me to a company called Tender Rose dementia care specialists who I know you'll be interviewing in a little while the founder of that company. And that was a very unique company that truly specialized and differentiated in home care, which there's not a lot of true differentiation in home care out there. And Tender Rose specialized in providing a very high quality service for folks who are going through cognitive decline. And it was very optimized in terms of the training, the quality of service and the outcomes. It was a very ⁓ expensive offering because investing in training and parent and paying very high quality caregivers a wage that would retain them to solve these really complex problems out there and then having an administrative team that has the problem solving capacity to deliver in that care. You know, it made for a sort of a more affluent offering. And of course, scaled that company and of course, that company got acquired as happens. And then I went into a larger national ecosystem. And in that moment, I was able I was part of a little executive team that was appraising tech for adoption into the home care space. And that was it was a bit accidental. I had been thinking about tech, but I really had a kind of aha moment. So I had sort of got that foundations of operations. I had seen how innovation home care is truly possible. And then looking at tech, I really activated my passion because I'm from very humble means I'm not from wealth. And you know, there's so many older adults who fall under the elder index. So they're house rich, cash poor, or even just in the financial milieu that we are now people are very concerned about their ability to afford long term costs. And I really saw the light bulb went off and I thought, my gosh, technology can really help us be better quality providers and maybe provide service options that are in a more affordable space. So I'm super excited about that opportunity. That morphed me over into doing some consulting. And at that time as well, I was providing care for my parents. I'm from Canada. And both my parents unfortunately have vascular dementia. So I needed to be very nimble and flexible about moving across countries. That got me to work for a company called Pando. health and Pando Health through that tech kind of space is a consortium of investors who are investing in smaller to mid-size home care agencies but they're very very unique because what they're doing is not rolling up those home care agencies they're providing infrastructure and support so those local home care companies can just do better be better so they don't intend on getting rid of all the staff or kind of changing that geographic footprint or really disrupting the kind of learned experience of those operators in that system but provide that wraparound and I had the privilege of morphing over into one of those acquisitions which was a company called At Home Caregivers to be their VP and in that space I'm bringing innovative concepts and different service lines into that ecosystem which is serving At Home Caregivers serving the Merin and Sonoma County area. So very excited. Miriam Allred (05:25) And I love it. Every market is truly unique, but you've told me a little bit about Marin and Sonoma County, and I do think they are particularly unique. Talk just briefly because it'll bleed into our conversation about some of the challenges that you're up against because of the geography. Paula Marks (05:40) Yeah, Marin County is super unique. It is sort of geographically located kind of like an island. It's north of San Francisco over the Golden Gate Bridge and it's very wealthy. So unfortunately, children of older adults and certainly caregivers can't afford to live there. It has the largest demographic of older, older adults. So 85 plus in the nation. And so there's all these older adults who are living on the sort of where you have to get to through bridges and they're by themselves. their kids can't, family caregivers can't live there, paid caregivers can't live there. And so it presents a really unique problem for staffing those cases ⁓ and getting caregivers to come there. But very, very high need and definitely means too. Miriam Allred (06:29) Yeah, so that's going to kind of set the tone a little bit for the conversation that we're going to have. We're going to talk about the workforce. We're going to talk about technology because that's a passion and focus for you. We're going to talk about family's perception to care and different pre-care and preventative models. And then also metrics for where the industry is headed. know me and that I love to go really deep on specific topics, but the conversations that I've had with you, can articulate like really well where care is and where we're headed. And I think this conversation and the topics we're going to cover today are what every home care CEO needs to be thinking about in more depth. And you're going to just like kind of crystallize it all for us. ⁓ So I want to start with kind of an open-ended question, which is around what has changed? We're going to talk about the workforce. What has changed with the workforce in the last couple of years that you've seen firsthand? Like in the last two to three years, what has fundamentally changed about the workforce and then why does that matter? Paula Marks (07:27) Yeah. Thank you your confidence, Miriam. I hope I can do as good a job as you've set me up to do. Yeah, it's really, really hard. And this is why I did so much homework because it's super important for people in the care continuum, but also for consumers to really, really understand the dynamic that's happening right now. So we have, as we all know, there's a caregiver shortage. I mean, it's acute, it's getting worse and worse and worse. So the caregiver to client ratio Miriam Allred (07:30) Yeah. Paula Marks (07:57) both on the family and on the professional caregiving side just absolutely is not there. So this is an acute crisis. At the same time, the total available need for care is escalating. So we have a fundamental supply and demand issue. In addition to that, Everyone is experiencing financial insecurity, even the affluent. lot of older adults, think 80 % of older adults are experiencing financial insecurity right now. And so a lot of people thought payers or CMS might be able to offset some of their long-term care costs. They're realizing very quickly that they can't. And they're also really realizing that how expensive care is, you know? And so that's a fundamental problem. And so ⁓ there's always been a bit of tension between what caregivers want and what clients want in that clients want sort of really ⁓ affordability, they want flexibility, they want short shifts and so on and so forth and caregivers obviously need to put food on the table, they have lives, they have families so they want consistency, they want long-term cases and those two are skis kind of going in the opposite direction but the thing that pulls them together is that both want quality and both want to get sort of out of crisis mode and be focused on living well. And that's sort of the place where I'd like to land is how do I be an excellent employer to the caregiver labor force so I can retain really excellent caregivers and provide them with great opportunities and career paths and also kind of meet clients where they're at. And one of the other things that's super problematic is because of the financial concerns and sort of the vagaries of the labor force. Opportune business models are coming into the fold, particularly in the Marin County where I live, and that's referral agencies or caregiver created home care agencies. And that's a real threat because While I can understand why caregiver would want to start their own agency, kind of cut out the middle person, the way that home care does well is by being a really great operator and running a business and being a licensed provider and doing billing and so on and so forth is very, different from being a really good caregiver. And that those different business models which aren't you know the employer on record actually becomes the older adult not the agency and and people are sort of cutting costs and optimizing for that model that puts a lot of people at risk it puts Clients at risk, you can't if you're a referral agency or private caregiver, you can't have backup You're not providing workman's comp. You're not carrying any liability You can't set schedules. You can't do training because then you're actually an employer and those are legitimately the number one things you need to be able to do to improve quality and on the caregiver side caregivers who are going into those businesses or being employed by referral agencies don't understand that they have to withhold taxes right and they don't have any kind of protections in the home and so in Marin County because of this essential tension we're seeing more of these business models pop up the amount of elder abuse is going up both elder abuse physical and both financial It's a real problem. Home care operators have to figure out ways to be sensitive to the crises that both caregivers and families are operating under, provide education about what is the value that they're actually purchasing and what does that mean for their long-term care journey. Come up with innovative options and meet them where they're at. That's what I'm trying to do. very complex problem. Miriam Allred (11:51) Yeah, like you said, I think what it boils down to is the caregivers and the clients and their families are both financially vulnerable. And here we have home care operators sitting in the middle trying to solve two really complex problems, like you just said. And it's all about education and communication and positioning to the clients and families and then also to the caregivers. Paula Marks (12:01) Yes. Miriam Allred (12:18) understanding and explaining why, yes, they're both financially vulnerable, but we have to be this intermediary and make it work for both of you. Something interesting you said at the beginning was like the ratio is closing. Do you mean that literally and that the ratio like client to caregiver ratio used to be higher and now it is literally lower? I was just curious. Paula Marks (12:35) Mm-hmm. Yes, yes, I believe in 2030 it's going to be. I think it's two caregivers to every client. maybe don't quote me on that, but anyhow, you can't just have one caregiver for an older adult, right? Like on a 24-7 case, typically you'd have three eight hour shifts per day. So that's three caregivers per day. So if you think about that ratio, most people think, one caregiver for one client, that's fine. It takes a village for one client. And so it's just a demographically unrealistic I mean, we are literally kind of snowballing in a fundamentally poor way. one of the things that I also want to point out that is really important to me is there the and it's a source of optimism really, that clients hold the key really consumers hold the key to really helping with where this is going. And what I mean by that is The way to kind of avoid this catastrophe is to be more preventative and be out of denial in care. So right now, what really drives crisis is reactive crisis driven care. And as a consumer of care, those are being clients themselves or family members. If you are waiting until the crisis happens, then all of a sudden you're affording 24 seven care after something that probably was entirely preventable happens. And that kind of puts home care and home care operators in that crisis driven model. But if you are willing and able to say, hey, you know, I'm not going to live in denial. I'm going to take my head out in the sand. I'm understanding even just as it's nomenclature now, 50 % of dementia is preventable. Most falls are preventable, but they're preventable in the space before you actually need care. So there's things that we should be looking at together collectively in the pre-care space. to kind of avoid that expenditure and accelerate the pain point which we have, which is the caregiver crisis, in advance. And that also compels home care operators and referral sources to get out of sick reactive care, which is a moneymaker and it stands in the face of true innovation and it upsets me. It's a horrible way to do business and into more collaborative partnerships with consumers. and other referral sources to kind of slow the catastrophic journey and be more preventative, more engaged in the pre care space. And you know what, there's always going to be a need for direct hands on care. But if you kind of come up with options and alternatives sort of in that space, then when it comes to care, it's not a crisis, you have more information about care, and you can be more empowered to deliver that care and deliver that care well. And so I want to call it out, it's not consumers could really, really help home care operators be better operators. The other way that they can help with that is by being realistic about the caregiver shortage. And just like home care operators, there's two levers that I think that home care operators can can really actualize still now to do better. And one is being a really excellent employer. So paying caregivers well and providing great care. career pathways. ⁓ Generating business is not an issue because the total available market and need is already there. It's embedded, but focusing on quality, providing quality services and bringing in the right business at the right time. How end users can help with that is not understanding that caregivers are people too, that they have to put food on the table, that they have families. And so not calling at the last minute, not asking for short shifts, not asking for split shifts, not asking for shifts every other day, understanding that like me as an operator employer, you are also in a sense a part of that employer and creating an opportunity where a really excellent caregiver is going to want to work there. And then not disqualifying caregivers on erroneous sort of features like how they look or so on and so forth, but more focus on the outputs like I, you know, oftentimes families will say, we want this kind of caregiver that looks like this and looks like that. And I'll have to really coach them and say, Look, it's really surprising. A lot of magic happens in the caregiver-client relationship and people that you think would be really good with mom might not be and people that you think wouldn't be are and it's really that sort of ethereal kind of empathetic connection where the kind of the magic happens so I really have to kind of Talk to, you know, in the intake, talk with families about how they can create an optimal work environment for the caregiver saying, you know, just like it's your first day having them in your home, it's their first day being in your home. And they have a really grave responsibility of working in a very private environment with someone who is going through a really, you know, crisis time in their life and they need to show up and be all things to all people kind of thing and so really being realistic and being helpful and not disqualifying them for erroneous reasons and working with the home care agency, know, not just firing people based on those reasons, but being a good problem solver together that helps a lot. So anyhow, that's a very long way of saying that in this crisis of demographic things that we can't Miriam Allred (18:10) Thank you. Paula Marks (18:15) function, we can't produce caregivers and put them on a shelf, we're not McDonald's. So this is kind of the reality that we're in. But consumers themselves can play such a big part in helping us to do better. You know, Miriam Allred (18:28) And the key thing that I'm taking away is the thing that we can control is quality. We as the home care company in the middle, we can choose quality. And so I'm curious tactically when you're talking to these clients and families, if there's not an alignment on quality and expectations and outcomes, do you turn those people away? Because you mentioned like the intake process and how important that is and how calculated it is. Paula Marks (18:33) Mm-hmm. Mm-hmm. Miriam Allred (18:58) But you, like anyone else, there's plenty of demand. People might come to you and they might not be a right fit, but do you budge on quality or do you turn a lot of people away because you have this like exact mindset? Paula Marks (19:10) Yes, I do. I played the long term game in care. if a client is calling and In spite of my best attempts to educate them about the reality of the labor force and what I'm operating in, they're just not meeting me there. I will say no to that business because I know that every home care company is having the same problems that I'm having. And I want to deliver well because that drives business. Since there's no problem with demand as an operator, the number one thing I want to optimize for is quality, right? Because quality helps me retain the labor force. Quality really drives my business because referral sources want me to solve that complex problem for them. Family members want me to solve that complex problem for them. And so that's what I'm optimizing for. And that I really honed at Tender Rose. So we, you know, very expensive offering, we were only available to a select few. And I knew that they were especially looking for quality service and sometimes that meant saying no to business Paula Marks (20:14) And so when I'm working with clients and I'm hearing that they are not aligning with how I can deliver quality, which is, understanding the operations that I'm working under and trusting me to be a problem solver for them within those kind of limitations like the caregiver shortage and so on and so forth and signaling that they're going to create and work with me to create an optimal environment for that caregiver then I will graciously let them go. I will always find them a resource but I am going to let them go back out there and have the experience that they're setting themselves up to have and generally speaking they will call me back and that happened a lot at Tender Rose where I had to be very it was a niche market and I to be very, I had to hard qualify our clients because we were a smaller company and that's just the way it was and I think it was a beautiful thing because by the time families circle back they would really get it and they would very much appreciate my honesty and my integrity. I speak to adults and people like they're adults and people and I'm transparent about what I can and can't do and I set realistic timelines and I send out an olive branch about how we can work together. And when I'm talking to families about choosing a home care provider, I say you're not purchasing the caregiver. That's a private hire referral. You're choosing the home care agency as problem solvers. And so I say work with an agency that has been in the in the local market for a long time, that has administrative staff who have worked together effectively over a long time because you want problem solvers. Things are going to happen. Home care is messy. We don't know how disease trajectories are going to roll out. They have lots of pivots and turns. And so you want to have an extremely good working relationship with your home care agency. You want to trust them, but they also need to trust you. And here and again is where consumers of home care can do themselves a service by working really well with the home care provider. Miriam Allred (22:20) So I want to ask specifically about this intake process. Oftentimes that intake person is incentivized to take all of the business that they can. But what you're saying is you don't want to set you, your team or your business up for failure. And so that intake process and the incentives need to be realigned around quality and expectations. It sounds like you've refined that. What does that look like? What metrics or incentives do you have in place to ensure quality over quantity at the intake? Paula Marks (22:53) Yeah. So coming from more higher volume businesses in the past, salespeople or client liaisons, which are de facto salespeople, ⁓ they are very heavily incentivized to say yes to all business. And having been part of a company that really has emphasized on quality, I now have flipped that around and say, salespeople, you should bring in business that showcases your team that works well for your team. And because what we want do it's not just getting ⁓ family into the care ecosystem it's developing a long-term partnership with them and so you really need to qualify is that a good lead for your team right now and that means really paying attention to kind of where staffing is at where recruiting is that I would tell salespeople when I'm doing sales training like really know where your teams are at is someone out on vacation you know when can you convert a 24-7 case in a way that you're going to be able to deliver well and if you can't having a very transparent conversation with that person I feel and this is me uniquely I don't see this happening that sales commission should be parceled out across the entire team as opposed to the salesperson. And I think that's kind of the most salient and best way of triggering salespeople not to just say yes to every business, but to say yes to business that's going to help drive the overall quality of the business because that's what's going to drive overall revenue, know, long term client retention, quality service, and so on and so forth. Miriam Allred (24:30) put you on the spot. Are you doing that? Are you splitting commission across multiple teams? And if so, which ones and what does that look like? Because it's a great solution and people need to understand how they could do it successfully. Paula Marks (24:42) Yeah, so I think that scheduling and recruiting and client care are very interconnected because they as I was talking to the team last Friday and I said, yes, salespeople are very, important. You will not grow without your salespeople. have to set salespeople up for success. know, salespeople in home care have to work very, very hard to develop referral relationships and it can take six months to get a new referral relationship going. And if you don't deliver well on that first referral, you can lose six months of that relationship building. And so they have to manage all those exterior relationships in a really acute way. So they're very, important to the team. That being said, scheduling and recruiting by really managing the labor force, which is the most volatile issue in home care, they hold the revenue for the entire company because they're ensuring that caregivers are showing up. They're ensuring that it's the right caregiver match. They're sort of their revenue you is kind of that consistent growth that's happening in the background and those two have to work synergistically together to run a very effective home care agency and I don't think that is recognized enough the internal sales that schedulers and recruiters and operators are doing all the time to kind of grow the business and I want to make that more front and center in addition to the fact that salespeople hopefully are managed and leveraging very long-term strategic partnerships, hope, not just one-off sales, but strategic partnerships with high-value referral sources. Miriam Allred (26:19) Yeah, and I think this is the challenge for a lot of agencies at scale. It becomes easier to silo out different departments. But like you just said, and like we know the client side, the caregiver side, the scheduling side, the care coordination side, all of that is one comprehensive function of the team. And so just be super mindful of splitting out departments and siloing sales from recruitment when really they go hand in hand. And I've talked to some large operations recently that have everything roll up to sales. And essentially it doesn't matter which department it rolls up to as long as it all rolls up to kind of one place so that there is a comprehensive picture across the full spectrum. And I think that's what you're getting at. And I really like this concept of splitting up the commission across those functions because really it is an outcome of all three of them, not just one. Paula Marks (27:03) Thank Yep, absolutely. Miriam Allred (27:10) So a couple of questions. want to kind of get to the technology piece because this is a focus of yours of these kind of like preventative care models and what technology is out there. how many families, we talked about crises and the catastrophic event and that's when families are calling. Of all of the volume calling into your operation today, how many of those calls are crisis driven? right now we need a solution, we need a caregiver in the home versus are people calling in proactively, preventatively looking for solutions down the road? Like if you had to quantify those two buckets of your call volume, what would they be? Paula Marks (27:49) Yeah, so I wish I had a different answer and I hoped to have a different answer, but I would say 90%. So ⁓ At Home Caregivers have done a fabulous job of having a great relationship with the hospital systems locally in Marin. And that has been our bread and butter business and we've done really well. So we skewed to sort of more of the complex medical. So I have to put that out there. ⁓ That being said, people are calling in reactive sick care. You know, they're waiting and waiting and that That's also a function of financial stress, right? Being in denial. ⁓ People are also calling for shorter shifts. They might discharge with 24-7 and they're going down to 12 and eights. I would say before they should from a healthcare standpoint. And again, that's due to ⁓ financial stress. And also I feel like perceived and a probably accurately held perception that home care really isn't the value that it says. it should be and I think that's because particularly in Marin we have a so many home care operators out there it's insane because the perception is that if you want to make money go into home care which is absolutely a very hard way to make money but there is because the available need is so high people are getting into the business left right and center but truthfully running a really good home care organization and providing quality care is extremely extremely hard and very few are very good at it and when operators come in and provide really poor quality service, it dovetails into that cynicism that unfortunately has referral sources in addition to consumers waiting to the last minute to get into a care partnership relationship with this established and local provider and a licensed provider. So I'm really working hard to kind of get out of that. But right now we're firmly in that. Miriam Allred (29:47) And that's a... And you're so right. It's an unpopular opinion. It's a hot take, whatever you want to call it, that part of the challenges that home care is up against is self-inflicted. We've done a lot of the damage to ourselves over the last 20 years, maybe 30 years, and we're trying to like claw our way out of it. And it's hard for me as kind of, I don't know, I've been in the space for six years, but like as a newcomer, it's like, wow, it's... We've got a mountain to climb to repair our reputation, but like we're talking about, we can control quality and we can control, partially control the reputation of home care in our own market. And that's what we should all be working so hard to do is to up that bar on quality and kind of rewrite our reputation. ⁓ And it starts with the families calling in and crisis and explaining to them what we do do and what we don't do and how high our quality bar is so as to help them. speaking to the technology side, you and I both want to air more on this preventative home care, this pre-care. And there's a lot of solutions out there and a lot of them that have been around for a long time. We think about wearables and monitors and all sorts of like in-home technology. Give us just kind of the high level lay of the land in your mind of like what's out there and what's working and or what's promising, you know, maybe down the road. Paula Marks (31:19) That's like so many topics in one, but anyhow, I'll do my best. So I just want to preface it by saying ⁓ Miriam Allred (31:21) Yeah, yeah. Paula Marks (31:27) poor home care. You know, we are the continuous amongst everything. So whether it's hospice or home health or payers or so on and so forth, it's really frustrating to me because you can't live without us. And yet we get so little seat at the table from CMS, from payers and so on and so forth. And part of that is because maybe as operators, we haven't done as good a job as we should. But a lot of that is because of our labor force. And where technology really comes in is it can help us accelerate our quality care. So I don't believe that technology in itself should be a revenue generator. I think it should help us be better business operators. And I think that's going to give us a seat at the table with CMS, with the payers, and hopefully with referral sources as we're able to demonstrate our outputs and quantify how we actually affect the care continuum because we know that health happens at home. We know with the whole social determinants of health and kind of where the whole CMS ecosystem was going in a hot second there is that really it's in the home environment where we're activating sort of or addressing some of those silent signals that kind of cause these preventable things to happen where we can kind of really affect change. And so ⁓ I would like home care operators to be ⁓ utilizing technology in a way that's really results ⁓ focused. My concern is there is a lot out there. mean, my God, know, hot second ago when I was looking at tech, was one thing. was like, wow, there's a lot. Now it's so much. And I as an operator, tech forward operator, I can barely keep on top of it. I mean, I'm trying to learn AI. I'm trying to get educated. I'm trying to be in the know because it's moving really, really fast. And one of the problems is I see, I see a lot of home care operators adopting technology as a bandaid to broken system. They're staying in the sick reactive care. And what I mean by that is they might do some of the things that I'm doing At Home Caregivers, but they're not doing it with intentionality. They're doing it as a marketing play. And so there's no one really looking at the tech. There's no partnerships that are really kind of moving the envelope of experience. for the care of person or even the family and that's a concern to me and some of those companies when they show do their pitch their deck is ⁓ well this is how you can you know reduce staffing ratios by saving this money by using our tech and I'm like no that's not the way this is supposed to be going this is supposed to be going about how you're improving quality outcomes you know like how you're preventing preventable events how you're developing partnership with people and so I am offering our technology at just a little bit below cost. But what I'm doing is really integrating it into our ecosystem and providing nurse care management oversight with the tech so that there are real people that are making real decisions about what the technology is elevating. And I'm holding my team accountable to that and the partnership that I have accountable to that. I'm very excited about that. Miriam Allred (34:54) Okay, tell us more, tell us more, tell us more in that, what technology is it? And you can be specific and name names. And then, like you were just saying, the application, like the execution, who owns what and what outcome are you driving towards? Paula Marks (35:11) Yeah, yeah. So I'm partnered with a technology company called Lifeguard Health. It's a company that I've worked for in the past and so I know them very, very well. They are fundamentally a software company and I think that's really important because they come from the healthcare space, not from an adjacent industry and kind of morphing into home care. So they understand my pain points and their software and their data science is truly attuned to elevating those key features in the home that are going to allow me to kind of avoid that, preventable event. And so it's a partnership. And that's just, you know, what we have to do. The problem is for me as an operator pushing innovation is getting families to get out of denial and to think more about prevention. I'm doing a lot of talks about the cost, the cost when you allow preventable events to occur, slow to kinds to go unnurtured and that is a motivator. But I'm trying to get not only consumers but also referral sources to help me be more in the prevention space so I can help them. And that's a real challenge because again the number one, I'm not sure if I'm answering your question accurately, I think I'm going to. But anyhow, the number one threat is that ⁓ people are still staying in sick reactive care. From the client side, it's that in denial, it's not going to happen to me. And from the referral side or even home care operator side, it's like, my God, there's so much business, Paula, I'm just running business as is. I don't have time to think of innovation. But the thing is you can't just slap tech Miriam Allred (36:29) You're doing great. Keep going. Paula Marks (36:52) on to home care, or just like I feel like you can't just come from technology and push into home care without being very intentional and very deliberate about what you're doing and how you roll it out. And so I'm trying to be very conscientious about doing that At Home Caregivers, But I'm not married to any one tech so much as I'm married to solving this really complex problem, which is how do we help families be more engaged in their healthcare journeys? And how do we help them avoid preventable decline and preventable catastrophic events and get into a real long-term care partnership with them, not only with the families, but also working with the care continuum to just provide better care overall. Miriam Allred (37:36) So are you trying to insert this technology in the pre-care stage, meaning you're working with a referral partner or say you get one of that 10 % families that are calling proactively. Are you trying to insert this technology there or does it make sense to put it in existing homes at clients that you have currently? Paula Marks (37:59) Yeah, so I'm iterating on both of those. ⁓ So I, it is a really hard. hard lift to get people to accept this in the pre-care space because I just there's so many things that we have to work against and it's a really a B to C play and that's really hard to drive. We all know very, very hard to drive. I'm also working with more ⁓ trusted advisors who are more risk adverse for kind of the overall wealth of a family to kind of be more in partnership with me. ⁓ But I also do think, I mean, it optimizes just general home care, even really complex. home care because it provides sort of in the background kind of information about how care is going. So it could be an integrated option and some people are doing that. I tiptoe on that because I really believe in consumer choice. And I want like anything with Tender Rose I would say to people like if I don't feel that what I'm offering has value to you and I've maybe I haven't done a good enough job of expressing the value to you. I don't want you to purchase it without any science in your own mind behind it. I want you to be a partner with me. So I want you to choose that with me together. I don't want to force it on you. I do I understand what you're saying. And I know for some people, it's kind of an embedded offering. And that may be the way to go. And maybe that's where I go. But for right now, I really want to have a larger conversation because it is what I'm trying to say in this whole podcast. is it's not the tech, it's not this, it's not that. It's like we're at a precipice. We have really pressing kind of overall structural problems, demographic problems, and each one of these things are not silos. They all have to work together. Clients and families have to be better consumers of care. They have to be more involved in their all-one-less journey. They have to make the deliberate decision to get out of reactive care. Home care operators have to understand that their care continuum now is expanded. the pre-care space, all the way through to things happen and so all of a sudden you know that's what we do. At the same time the care ecosystem, the payers, the hospice system, the referral sources also have to get on board with that and it has to all happen together and I feel like when you force something I feel just it's just a personal opinion. I actually will take myself as an out as an operator and just say this is a Paula decision. I feel like it's more impactful when it is a deliberate and conscious decision to engage with. and I guess as an operator as a business person, I have to figure out how to make that happen. But here's the thing. I feel like if I can do that and do that well at scale, I'll be more successful than pushing it on someone. Because I feel like When you operate in a situation of choice, it compels me as an operator to participate. If I just force it on you, maybe I can stand back and not really engage with the technology, which I do see home care operators doing and the technology fails. It doesn't fail because the technology is not very good. It fails because there's no thoughtfulness around the execution or the conversation about the why. Why are we doing what we're doing and where does it fit in our business model and how is it important? ⁓ Is it just marketing? Are you thinking of it as just a revenue operator? Or are you using it very intentionally and deliberately to be a better operator, period? And that's just, know, Tender Rose. I'm so excited that you're talking to Jim. Tender rose. We focused on being an excellent employer and providing quality service and we won. we won the business, you know, and I feel like that can be done in any business at any level at any price point, but it has to be done very conscientiously and very deliberately in partnership in real partnership with people. And when I say real partnership to I want to call out that families are in distress. Families are in denial. These are things that operators understand families because of where they're purchasing home care. They are not very good reporters sometimes because of the stressors, like there's, it's so complicated. And so we have to be very tactful in the conversations that we're having in the way we roll them out. But if you're accessing all referral sources, families, operators, staff, caregivers, if you're having a conversation and leveraging all those different vantage points in a really open and transparent kind of way, I think that's what's going to make things really happen. I'm super excited about that. Miriam Allred (42:40) So, yeah, so staying on the ground level of technology for a little bit longer, who is more resistant, the client themselves or the family, the adult children? Who is more resistant to the technology, the client or the adult children? Paula Marks (42:56) Yeah, you know what, Miriam, this is really crazy to say, but I think it's actually the referral sources. And I hate saying that because those are my partners in the care continuum. I think that the clients and families are actually much more tech forward than referral sources will venture. And I sometimes am concerned that that's because so many of our business models are in the sick reactive care and it's kind of like they can't envision out of it. But typically, and I've know, I've sold these products before and when I've talked, yes, older adults are concerned about AI. It's not the world that they grew up in but they're smart people and when you explain the why and the how they they're like, my god I feel so much safer already and for family members who are sandwich generation and they're trying to work They're trying to bring up their kids. They might not live closer to their older adults Technologies are a no-brainer because they allow them to kind of relax knowing that there's a layer of prevention that they can count on that's in there So I actually see the greatest challenge and that's I'm exploring B2C options is really in referral sources. ⁓ being part of that kind of like change and going forward they all get it they're like paula this is the greatest i love it you know yeah yeah yeah but you know almost like home care operators we we have such a heavy lift all of this i want to say this ever so graciously anyone who works in home care or in the care of older adults is literally working with their hair on fire it's it's just so crazy and so asking those people to change their business models is really hard and i and i i understand I get it. It's really hard I have very little time to spend on technology while also running a home care agency and I wish I had all the time in the world just to do this one focus thing, but it's just you know, that's not in the cards and that's why I feel like ⁓ Client education is really important because clients and and older adults and families asking for this and Understanding it is really going to be the thing that's kind of kind of do that cascade of all the cards and pivot it in really powerful directions And guess what? It's in the direction that all of us want. want, you know, home care can stop entire communities from functioning because it affects everyone. It affects families, it affects children, it affects hospital systems and so on and so forth. If we could just be more preventative, more proactive planners in care, our entire communities would run better and we all know it. We just have to do it and we have to take that first step, work together and so on and so on and so forth. While being very aware, that we also are kind of an emergency medicine right now too, know, or I should emergency non-medical in-home care. Miriam Allred (45:45) Yeah, this is so interesting to hear you say in that the referral sources can be the gatekeepers to the successful implementation of technology in the home. I think that's a really interesting vantage point and it's just fascinating. I'm just stewing on what that looks like in that. So maybe give a specific example just so can fully understand this. Say it's a referral coming from a hospital. and they come to you and they kind of explain the expectations, but then pass you that referral. Can't you insert yourself and say, here's what we offer and how we offer it and slot the technology in right then and there. But then does the hospital, for example, have authority to be able to dictate what you, what you can and can't do because it's a, an important referral. Am I understanding that right? And that like the expectation is placed on you from the hospital. Therefore you have to do what they say. Therefore they can be the gatekeeper on technology. Paula Marks (46:42) Mm hmm. I'm not sure if I'm totally understanding about I'll take a stab. I wouldn't hospitals are more ⁓ they want to get people out of the hospital. So they're very heavily weighed to just general home care. So I'm not really spending too much time explaining the technology for them because tech this technology is pre care. It's not reactive care and hospitals are fundamentally kind of that's the space they're in. But if so. Miriam Allred (47:08) So which referral sources? So yeah, then which referral sources are gatekeeping? Paula Marks (47:10) Yeah, yeah, yeah, yeah. Thank you. the so and I Tender Rose I worked almost exclusively with trusted advisors. So these are people I know really well. When I say trusted advisors, those are those who are resource who are risk adverse for the long term care of a family or client. So they're the wealth managers, fiduciaries, elder law attorneys, geriatricians, and so on and so forth. ⁓ What I'm finding is, is they are making assumptions about the lack of tech savviness of their clients or their ⁓ concern because it's technology and AI and sort of it's fearful, fear based. And so they are really, really excited about the opportunity, but they're not. partnering as much as I would like them to like they'll say to me Paul I have seven clients that I'd love love you to get the technology in and then they don't make the referral or they don't handhold the referral so I I'm really good at closing once I get the person on the phone but I'm not able to you know I'm not even able to get to that place and so I don't see that as their problem that's my problem is a business problem like I need to somehow develop the language or so on and so forth and I just started the tech a couple weeks ago so it's it's not it's super new. So I haven't even got into having those conversations yet. ⁓ But what I'm trying to do is kind of do a lot of talking around the problem and the costs of care and kind of the realities of a home care because I'm speaking to very intelligent people. So if I explain the social problem, the why this is really important, and how it affects their clients, I'm hoping that will move move the envelope around risk aversion around tech because I know at Tender Rose, we used a lot of technology. and when the outputs for using the technology are so high risk aversion goes down and you're more accepting ⁓ and the technology that I'm using at at-home caregivers is extremely privacy protecting it's totally encrypted it's you know, not commercialized. mean, it's the most ground level tech that you could possibly use. So once I get to have that conversation with people, they're like, ⁓ okay. But in people's minds, they think they have all these ideas about this, that and the other thing. ⁓ And that's, you know, a super challenge. So it's me, it's my problem that I need to figure out and figure out a way to do better. Miriam Allred (49:37) Yeah, well, well said. I kind of threw you there with the hospital referral source, but you're talking about these trusted advisors specifically that can help you get it in front of the pre-care families and that needs specifically. I was thinking of, you know, hospitals and SNFs and those people referring you in business, like, can you slot it in there at the start of care? there's the pre it all blends together. There's the pre-care, there's the start of care, and then there's the evolution of care once the caregiver is in the home and and what Paula Marks (49:46) Mm-hmm Mm-hmm. Miriam Allred (50:05) point does the technology make sense and you know at what point are people most receptive it's like you're you're articulating this really well and that it's just these conversations are really complex and there's a lot that people understand there's a lot that people don't understand and you are trying to just help them understand all of this complexity in a way that they're receptive to and then can make the best decisions possible and then you help them throughout the process because It changes what they need now versus in six months versus in 18 months. So many factors come into play and you're navigating it in real time every single day. Paula Marks (50:41) Yep, absolutely. Miriam Allred (50:43) So two more things that I want to kind of wrap up with Paula. You've shared so much and to be honest, I'm still kind of like chewing on some of this as you're sharing it in real time. You are very in tune with where we've come from and kind of like where we're at. And you've talked really well today about like the problems that you're trying to solve. I'm curious what indicators or metrics you keep an eye on. Paula Marks (51:07) Mm-hmm. Miriam Allred (51:07) that tell us where the market is heading. You're very focused on solving these problems, but ultimately we want to get to a certain place. so there's a couple of metrics that you shared with me that I want you to share of that you're keeping a pulse on that help you identify where the demand and where the market's mindset is heading. Could you share those? Paula Marks (51:27) Yeah, absolutely. So, so I know that we're in reactive sick care. When families are waiting and waiting and waiting to call us at the last minute, when the lifetime value on a client is really low and they're asking for short shifts and their schedule, they're changing the schedule a lot. That is a 911 for me because it's almost as an employer, you know, with a contracted labor force of caregivers, like caregivers can write their ticket, really good caregivers can do pretty much what they want. So I need to give them a good employment, long shifts, good hours, stability and so on. and so forth. So it kind of snowballs in a really detrimental space where care quality goes down and down and down down down. And so that's something that I'm paying attention to. ⁓ When I start to see things shift is when I get engagement early. my client care liaisons are meeting with the family, doing an assessment way before care is even needed. And that is starting to happen. I'm starting to see that with the technology. And so we're getting into a trusted relationship. Hopefully they've vetted other home care agencies because I always tell people, you you want to work with people you trust. You want to work with people who responsive you want to work with people who are good problem solvers do your shopping early and do it well and then get into engagement relationship and kind of trust and so when I start to see that and they dip their toe into that kind of pre-care space and leverage some of the opportunities that I'm offering At Home Caregivers and then that case grows into home care and we see it shift from ⁓ short shifts, you know split shifts and shifts every other day into kind of a more slow grow trajectory into a long term care then I know that we're moving from being just a vendor of crisis care into a long term strategic partner who's working collaboratively with them in the care continuum. And that's kind of like the prize, right? And I and I'll see it too, just as an operator, schedulers aren't stressed out, recruitings doing fine, the salespeople don't feel like they have to close every case, like it was going to slow the operational pace of home care. So we can do kind of what we all want to do, which is focus on quality care, But unfortunately, we operate in a space in a work environment where it's very crisis driven. And if you're an empath, when things don't work out or things go wrong, it's really, really a horrible experience. And I see that with my staff, everyone really owns mishaps. And it's terrible. And so what I want to do, like I said, while back is I want us to bring in the right business So everyone on my team is feeling really good about their job They have all the information they need to deliver really really well and we can grow collectively together and that we have really happy families and so those are kind of like the change in purchase of home care and their earlier conversations ⁓ and maybe even some different referral sources to like more in the proactive planner space like I feel that employee assistant programs are a great opportunity for home care to engage with any community system where you need adults, children to be functioning better. That's a good referral for home care. That's a good place to engage with because we are literally going to help our community be able to do that better. ⁓ So yeah, different, very, different. Miriam Allred (55:07) You said earlier that in home care it just feels like our hair is on fire all of the time, I'm curious what success looks like to you. In my mind, it's the chaos lessens and lessens because you're taking on the right fit people, but then also your team's endurance and ability to manage chaos improves. And so the equilibrium is the chaos is less and less and their ability to manage the chaos improves. And so there's this kind of sweet spot that we're striving towards, is, reduce the chaos. It's never going to go away. We're never going to get chaos to zero because of the complexity and the people, but reduce the chaos and your team's stamina and ability to handle the chaos gets better. And that's kind of the layer that we're striving for, which is we can do this long-term and sustainably because we're just getting a little bit better and a little more dialed in every day. Is that how you would describe it? Paula Marks (56:03) Yeah, absolutely. And I'll just say, I'm very interested in AI. I'm scared of AI like everyone else is. But one of the things I love about AI, live in a very our ecosystem is a very feminized, very racialized ecosystem. We have amazing people doing amazing work who are often not valued for the work they do. And right now with AI, the number one traits that are going to be very important for the labor force of tomorrow is high emotional intelligence and high emotional talents is reading the room, understanding when to be present and to be in the background, all of those nuances that women and people of color have to do to survive in the world. That is becoming super, super valuable right now. So I want to create more opportunities for career pathways for those individuals because they are the future. I also want to create more confidence because I feel like Home care operators do we do amazing things every day, but we just don't get the respect that we deserve. And I just, you know, as we see the shift to valuing more of the things that make us our most our most human selves, which are becoming more valuable in this AI environment, I want to see my team saying, you know, my team At Home Caregivers have been in this space for decades. I mean, they've done it, they have. so much institutional knowledge, it's amazing. And what I would love to see is the confidence and the valuation of that go up. And again, I would like to be able to pay better and create more career pathways and more opportunity because, you know, they deserve it. And also, you know, that's what's going to help drive quality care. So I'm really excited. I'm nervous, but I'm also really excited. And as I say, I'm trying to get more and more educated using AI tools, like I mess things up and AI can be so I think I've got something all figured out. It's really cool. And I presented is full of mistakes. You know, we're learning all the time. But I think I understand where this is going. And I'm actually really, really excited about it. Almost in part because of I'm a realist, like we have a huge problem here, supply demand problem. And like it or not, you know, we have these tools now that can really help us scale quality So I've scaled a premium niche product and that's great. But now what I want to do is someone who's, you know, the people. ⁓ I know I'm a privileged woman, but I am part of the people. I want to be able to scale that quality at a price point that's affordable for everyone. And I'm really, really excited to do it. And I have more questions than answers. I think that we're going to figure this all out together if we remain curious and if we can really get people thinking realistically about care. know, as I said, and I'll say it again, consumers getting their head out of the sand, realizing that it's up to you to change this trajectory, not your doctor, not your home care provider, not your wealth advisor, it's you, only you hold the keys to reducing your care and then working really well with the home care company, being a realist about kind of how that company operates. then home care companies involving technologies so we can demonstrate results so we can get a seat at the table with the payers with CMS and so on and so forth. have to be better operators where we can showcase and demonstrate kind of the outputs that we're able to do and that's You know, that's a lot of different things, but I'm, I feel like we can do this, we just have to be having more conversations like I'm having with you, and kind of get people feeling a little hot, like referral sources, they need to get out of sick care and into preventative well care. And they just need to be very deliberate and partner. I had I was speaking at a rotary, and this one doctor said, Well, you don't provide real fall time detection. And I said to her, said, so do nothing. Like I can, I can, you know, we have some alerts that are along the lines of critical inactivity. So I'm going to solve the found down problem where a senior has slipped and been on the floor for three days. Can I do real time fall detection? It's available, but people can't afford it. So that's the thing. Like there are solutions for all these things, but there's a friction at price and privacy. And so I said to her, said, that's the problem that drives me crazy because it's not perfect. You're going to do nothing. What I say is like, let's move forward into this new future. Let's make mistakes. Let's talk. Let's communicate. Let's work together to solve this problem because no one is going to solve it for us. We have to solve it for ourselves. ⁓ you know, the more conversations we can have and poke people into feeling, you know, like they need to act. You can't just sit in your office as a wealth advisor and be like, God, they're spending down all their money because mom had a fall. It'd be like, I remember Paula. She said she has this technology and it can really help with some of those issues. should have. I'm going to get on the phone. I'm to call every client I have and I'm going to say, get lifeguard in there right away. You know? Miriam Allred (1:01:15) Paula, I admire you so much. You know, we're speaking at kind of a high level today, but you, like everyone listening to this, is on the ground floor day in and day out. And I love your optimism and your forward thinkingness and your curiosity. You've been at it for a lot of years. And what you thought personally five years ago is different from what you think today. Like this industry is changing and morphing into something different. And I love that people like you are willing to stay in it. We've seen a lot of people exit the last few years because it is hard and these problems do not have simple solutions. But I admire you so much in that you're willing to keep your head down and keep working and chipping away at these problems and you're optimistic and you can make light of it. You even your consciousness right then are like, it's really hard, but we have to kind of smile and laugh and let things kind of roll off our shoulders. But we have to stay focused on the the deeper rooted problems and just slowly chip away at them and hope that we'll be in a better place in five years from now. Paula Marks (1:02:18) Yeah. And Miriam, I have to just thank you for doing what you do. You have real conversations with real people, and you're super smart. And you are doing the lift by getting out there and talking to providers and asking probative questions. And I so, so, so deeply appreciate what you're doing. And I'm so grateful for the opportunity. Thank you so much. Yeah. Miriam Allred (1:02:43) Thank you so much. This is the small part that I can play. know, my part is small and niche and what I do, but I've said this recently, like, I'm 30 years old and what is home care going to look like in 10 years and 20 years and 30 years? And it takes all of us, like that's what you're saying. It's collaborative. It takes every single one of us rewriting this narrative and redefining home care and thinking about pre-care and making that the highest priority to our referral sources. It's all these micro conversations that all of us are having and that will take us to where we want to go. And so your part and my part and what we do and what our day to day looks like, like we're all in it together. And I'm passionate like you. It's like, how do we make this a little bit better? How do we come up with solutions? How do we, how do we pull our expertise and skills and strengths together rather than being siloed out in different markets and trying different strategies. like, let's all work together to solve these really complex issues. And so you're a great example to me and I'm happy that we had this conversation. So Paula, thank you so much for joining me. I highly recommend that people reach out to you. We didn't touch on like your vast experience with technology, but people can reach out to you and ask specific one-off questions in that sense, but we will stay connected and we'll just kind of see where this road takes both of us. So thank you, Paula. Paula Marks (1:04:02) Thank you so much, Miriam. Appreciate it. Thank you, everyone.