Miriam Allred (00:10)
Hey everyone, welcome back to the Home Care Strategy Lab. I'm your host, Miriam Allred. It's great to be back with you in the lab. Today I am joined by Megan Casey, a executive consultant at Momentum Healthcare and Technology Consulting. Megan, welcome to the lab.

Megan Casey (00:25)
Hi. Thanks for having me, Miriam.

Miriam Allred (00:28)
You and I are both here locally. We almost could have been recording this in person. I'd even think about that. We're both right here in Fort Worth, Texas.

Megan Casey (00:34)
Yeah.

Miriam Allred (00:36)
But instead we're cozy at our home offices having this conversation, which is equally great.

Megan Casey (00:40)
Yes, yes, absolutely.

Miriam Allred (00:42)
Let's start with your background. For those that don't know you, tell us a little bit about yourself and your family and your professional background.

Megan Casey (00:50)
Sure. I live right here in Fort Worth, Texas. I am not originally from Texas. I am from small town in upstate New York. very proud to be a Texan now. I never want to live in snow again. This is my 20th year in healthcare. and my 14th year working in the home care space specifically. spent just under nine years at Accent.

And about three and a half years at LiveWell before joining Momentum as an executive consultant. So very happy to be here.

Miriam Allred (01:28)
Talk a little bit about your roles at both Accent and Live Well. what was kind of like your purview operations, recruiting? You know, what were your areas of expertise?

Megan Casey (01:37)
Sure. So at Accent Care, I actually started as a field supervisor. so I did the recruiting of caregivers. I wasn't a field supervisor very long, got promoted. I was an area operations manager for a long time, director of product development. I ended my tenure there as an area vice president over health alert, so the technology systems that Accent Care used. and then at LiveWell, I was the senior vice president.

Overseeing operation strategy, VA relationships, sales, and and and growth, small startup to a pretty large organization in just over three years.

Miriam Allred (02:12)
Yeah. And large footprints for both of those companies, correct? They weren't just kind of single site, you know, locations, accent care and live we'll talk about just kinda like size and footprint.

Megan Casey (02:22)
Sure. So accent care was pretty small when I joined, I guess, relatively to when I left. I think they had 12 to 19 states for their personal care line, but of course they served across the continuum. So home care, hospice, and personal care. Live well was strictly personal care, with some additions of other service lines under different names towards the end of my time there, but across a third total of 32 states that we could provide business in when I left.

Miriam Allred (02:52)
Yeah. So you really like run the gamut of like small operation to enterprise and operation and every single role touch like every area of operation. So your experience is super vast. I think, you know, your recent maybe claim to fame is around like veterans care. I've interviewed some of the previous executives of Live Well on the show, and so people might know kind of that background, but one of your roles as a company claim to fame and even yours personally is like working with veterans. And so I approached you and I said,

There's kind two topics I have in mind. One would be, you know, the administrative side of veteran care and working

Megan Casey (03:27)
Yeah,

Miriam Allred (03:28)
with the the associations and building those relationships and like kind of that side, but then also the actual care side, the service delivery to the veterans and what that looks like and the obstacles that you're up against. And I said, you know, you pick and you you decided we should focus on the service delivery, which I'm really excited about because I don't feel like I have talked about this a whole lot, but who better

Than you to talk about this, having worked with probably thousands of veterans and families. And you and everyone listening to this that works with them knows about like the pride and the stubbornness and the just the uphill battle it can be to deliver that care to them and to get through to them. And so we're gonna talk about that. I I said to you, I want you to share stories and experiences

And so I guess we'll just kind of like open that can of worms of what what is the biggest barrier? You know, there's all sorts of like logistical things around veterans care, eligibility and affordability and all of that stuff. But the bigger barrier is oftentimes the veteran themselves. So explain explain that. Like break that down what you think that means and looks like.

Megan Casey (04:27)
Absolutely.

Yeah, absolutely. So I guess to explain that side of it and and kind of the stereotypical veteran, I think you need to understand why I love working with veterans and why I immediately said no, Miriam. This is what we have to talk about. my grandfather was a World War II veteran. and

He was not the stereotypical veteran. I never saw him wear the hat. I never saw him walk around in his uniform. In fact, the first time I ever saw his uniform was at his funeral when I was 16 years old. And he didn't really speak about his military service. He didn't get care at the VA. He had a lot of medical issues, but he went to a general hospital. and he wasn't a career

Military person by any means, but he's he served a few years for our country and served in active war. and I guess when we think about a veteran, or at least growing up in small town America like I did, you think of the cute little man at the diner wearing his hat, proud veteran. He's got his pins on, he's wearing a jacket that says veteran, and he's so proud of what he did for the country. And that's not what veterans all look like anymore.

There's

people who aren't proud of what they did, or people that were coerced into military service. They were drafted. or people that had to do things that they aren't proud of during their time in the military and they don't get care at the VA. And female veterans, I a lot of female veterans faced really tough situations, especially in the Vietnam era.

And so when you think of what does a veteran look like today, it's it's not always the ones sitting there holding the flag at the Memorial Day parade. it's people that you would never know. And and I want to make sure that we're advocating for all of them. And so being able to spend time with veterans and the thousands of of veterans' families that I've helped over my career.

I've gotten to know a lot about them and what makes them tick and what makes them stubborn and what makes them say yes and what makes them say no. And there's not a there's not a shortcut. There's not a, this is going to work on every veteran, period, because what works on you won't work on me. We're different people. And I think it's really just about understanding how their military service plays into who they became as an adult. And

how you're you can use that to help them access care.

Miriam Allred (07:18)
Wow, great start, Megan. That I was not even expecting that, but that was better than I could have even imagined. So fantastic start. And thank you for sharing the personal experience. would you say that more often than not, there are more veterans out there like your grandfather than the cute little man wearing the veteran hat at the diner,

Do you think that's the case?

Megan Casey (07:39)
I do, I do. I think there's more veterans that aren't loud and proud about it. but you don't see them as much, right? You go to the VA, you go to the VSO, you go to the VFW, and and you're seeing the ones that are loud and proud. And hey, here I am, I'm a veteran. but you don't, you just don't see everybody else because they're not screaming about it. And and I think it's good to scream about it. They should be proud of what they did, right? Veterans wrote a check.

that said, I will pay any price up to and including my life for our country. but they don't they don't all wear it with pride and that's okay too.

Miriam Allred (08:18)
Yeah, and that's just a really good reminder because I naively think of the vets that I see that are loud and proud, and I don't think about all of the rest, but there is that silent majority that are out there that we shouldn't forget about. And they are likely the ones that need support and need help, but don't want to publicly like ask for it or be in the in the limelight by any means.

Megan Casey (08:45)
Absolutely.

The loud and proud ones are already at the VA. They're already at the resource fairs. They're at the stand down. They're they're talking to their VSO. They know what benefits are out there for them. And I love serving them as well. I think they're awesome. They'll sit there and tell you all their stories. but the ones that aren't you know, out there talking about their time in the military, often they don't know what benefits are available.

I think it's something like 30% of veterans end up accessing their community care benefits. And and I'd have to double check those numbers because it might be old. there's millions of veterans in the US that are eligible for community care that could get this homemaker home health aid benefit, they could get aid in attendance. And I I spoke to a veteran just a couple of weeks ago and a female veteran, and I said, Do you know what aid in attendance is? And she said, No.

You should, you should know now for when you need it and to advocate for your fellow veterans because who are they going to trust more? The person on TV saying, Hey, you could get this, sure I could, or the person who actually served and and has has accessed it before.

Miriam Allred (09:56)
Yeah, I'm glad you even mentioned that statistic. I don't have it in in front of me and we can look it up and include it. But it's it's some wild statistic of millions and millions of veterans that have access to these benefits that are not taking advantage of it. And so we've seen

Megan Casey (10:09)
Yes.

Miriam Allred (10:09)
a ramp up of just like veteran care and veterans being in the in just like the public eye from like a healthcare standpoint. But there's so many that aren't taking advantage of it because they don't know. And that's

Megan Casey (10:21)
Yes.

Miriam Allred (10:22)
where I kind of liken it to like the guide program right now. It's like every home care.

company should become a educated, but then become a walking billboard for these

Megan Casey (10:32)
Yes.

Miriam Allred (10:33)
types of services because everyone you come in contact with in your neighborhood, at your church, at the grocery store, at the post office, there are people that qualify for these benefits that just have no idea. And so there's just this unlimited potential to educate. So, so how did this, how did this start for you? I mean, from your grandpa, obviously, but then live well

decided to approach and you know, kind of go after veterans specifically, you I think are one of maybe the most connected people. And I we're not gonna get too much in the into the administrative side, but you have become so well connected in just like the VA sphere. How, how did you even start that? How did you get educated? How did you learn about aid in attendance? Like what did your journey look like just getting educated yourself?

Megan Casey (11:21)
Stubborn and I just kept calling till they gave me the answers. And I I, as I was doing it, and I actually had to call the national VA to get them to help me with information, which if you've ever tried to call the national VA, is impossible because right, it's it's a big organization. How do you get the right person on the phone? but I I got on the phone with them and I just said, I'm in my 30s and I'm

Educated

and I work in healthcare and I'm having trouble figuring this out. So how is my grandpa going to figure this out? Because he's not tech savvy. He's not gonna wait on hold for five hours hoping that the right person picks up the phone. He's not in the my VA experience app or doing the texting with his provider. He doesn't have that luxury, he doesn't have that patience.

so if I couldn't figure it out, how do we expect the veterans to? And so I just became a thorn in their side. And if anybody at the VA sees this, I'm so sorry I did it because I love the veterans. but it worked. I just kept asking questions and demanding answers because the veterans deserved the answer and and I wanted to be able to give it to them.

Miriam Allred (12:43)
And how can they say no to that? How can they hear someone as passionate and fired up as you and like turn you away? That should motivate and inspire them, right? I'm sure you talk to people that, you know, they're kind of doing like working their nine to five, you know, picking up the phones and stuff, but hopefully you honestly like inspired them to think differently about the care that they're doing.

Megan Casey (13:04)
Yeah, absolutely and and you know, I think

During my time there, I I I I gained a lot of respect for the employees at the VA. They are working short staffed, you know, they have thousands of veterans in their caseload. And that's just at the local VA. That's not even thinking of the folks at Tri West and Optimum who actually manage these benefits. And I know that they're overworked as well. And they've got 500 providers banging down their door saying, please give me a contract. And they hope that those providers are going to operate well on it.

Unfortunately, if you get into the VA healthcare system, you're you're usually in. And that doesn't matter if you're doing a good job or not. So if they have 50 providers sitting in Fort Worth, they're like, hey, we're we're maxed out. We don't need any more. Okay, but 48 of those aren't doing a good job. And that's where I pushed back. Like, sure, you've got this network capacity. Are they doing a good job? Are they really taking care of the veterans? and I just I'm just stubborn. I just kept calling.

Miriam Allred (14:05)
Yeah. So

let's talk about like the first, I don't know, 10 or 20 families that you worked with. Like think back to those first veteran clients. I'm sure some of those like stand out in your own mind of just like experiences that you had. Think about caring for those first few. What did you learn? What did you know? What was maybe obvious? You know, having a home care, personal care background. Like you knew about care and you knew about scheduling and you knew about the caregivers, like you knew all those dynamics, but what did you learn that was

different right away that was harder or different than kind of traditional home care clients.

Megan Casey (14:40)
I

mean, this is going back 13 years, right? To my first veterans in California. And I think some of the most shocking things for me at first were how appreciative they are of the service, right? I worked with a lot of private pay clients. They're paying money for the service. And yes, they're appreciative, but they're paying money for it, right? Veterans are getting this as a benefit. They're so appreciative of having a caregiver in their home.

They're also reluctant. They they have a special usually relationship with their family caregiver or their daughter or their wife, whoever's in the home. No, she's gonna continue doing this for me because this is what she does. And so I guess I was shocked around not just the appreciation, but the reluctance to using.

Many of their hours or all of their hours. You know, the VA doesn't give a lot of hours. It's based on a case mix tool. So if a veteran gets 16 hours a week, they might say, I'm gonna use four. And I'm over here as an operator, like, you should use all 16. These isn't there's not rollover minutes. Like you have to use them this week. but so many of the veterans had great family support or

Their wives, they were relying on their wives. Is that a good thing? Maybe not. because you know, we want to let the wife be a wife and not just a caregiver. But it then those hours were there as they progressed. And and sometimes it was just getting in the door and some of them would use an hour, some of them would use two hours until they they realized that they needed more and that they trusted more.

Miriam Allred (16:23)
What does that conversation look like when they're not familiar with the benefits that they have and the hours? Like oftentimes you're coming in and educating on all of that. What does that conversation look like with the veteran themselves and the family when you're explaining all of this to them? Like what is their reaction?

Megan Casey (16:38)
Yeah, I've I've actually had it go both ways where I've sat down and said, Hey, you get 16 hours a week or whatever. And they're like, This is amazing. That's more than I need. I was thinking, you know, two hours on Monday, two hours on Friday, this is what I want help with. and then I've had it go the complete other way where they're like, What do I do with the other 160 hours in the week? You know, how how am I expected to care for my father or care for myself outside of those hours? Because for somebody that's

Early on in their aging progression or disease progression, they don't need a ton of care. But when you have a veteran who's high acuity, who's had multiple strokes, has Parkinson's, has Alzheimer's, is an elopement risk, 16 hours is not going to do it. And yes, we can go back to the case manager, we can ask for more, but the VA is not paying for 247 personal care. That's just not something that they do. And so having to have that conversation with families about not just the

the

capacity of the benefits, but where does it, where does it stop? Like what can they do? And what do they need to do if they need more care than that? Is it time to look at placement? is it time to move them a VA nursing home, right? They're they're beautiful. They've just opened a bunch more. so just kind of talking through what the program is and what the program isn't with them.

Miriam Allred (18:03)
And then what their options are if they need additional care, because that's also

Megan Casey (18:05)
Yeah. Absolutely.

Miriam Allred (18:08)
opening that can of worms of just like aging in place and what their options are and what long term care looks like and explaining all of that. you're referencing that that there is and can t oftentimes be family involved and helping in nearby. I know in your more like recent years you've been doing like more rural veterans' care, and I think in that case sometimes there's not family nearby.

Could you quantify

Megan Casey (18:32)
Absolutely.

Miriam Allred (18:33)
like how often there's a family member involved and hands on versus not? And is there like trends there with veterans or no?

Megan Casey (18:40)
I it's probably fifty fifty. And I think I don't know if the rural markets are so much different. you know, if you think of a veteran in the middle of nowhere, Alaska, they're probably living in the middle of nowhere, Alaska, to be away from people. that's why I would be living in the middle of nowhere, Alaska. but that self-isolation comes at a cost because who's gonna check on you when the caregiver's not there? And who's gonna check on you?

When the blizzard hits and the caregiver can't make it there. So there's a give and take. some VAs do allow for family caregivers, right? Not somebody that's living in the home most of the time, but the neighbor or the friend from church or the granddaughter down the street that comes in and cares for them. And that's frequently a way we get a new veteran to accept care. You know, they're they're needing just the bare minimum right now. And

Maybe their granddaughter meets those qualifications. I I remember very specifically a veteran. I went out and did his assessment. And he was still very mobile and very capable of doing things himself. He had maybe four or five cats and as many motorcycles in the yard to match. And he still rode his motorcycles, which I thought was the coolest thing. And we're sitting there talking and and he's telling me what he needs help with and.

So let me look at his care plan, stage four lung cancer. But he wasn't showing symptoms at the time and he wasn't letting it change what he was doing at that time. And so he didn't want care. And we talked about what's your plan? What are you going to do as your symptoms get worse? And so he ended up bringing his granddaughter in, I think it was twice a week, for housekeeping.

To

be in the house while he took a shower, because he didn't want his granddaughter to help him take the shower, but to be in the house in case something happened, make sure he ate, make sure he took his meds, do his laundry, all that jazz. Three months down the road, he couldn't do anything for himself. And his granddaughter wasn't the right person anymore because she needed to be granddaughter during that tough time and not caregiver. And so at that point, he had gained enough trust with me where.

I was able to send in another caregiver to start doing that full care and to give him the dignity and the quality of life he deserved towards the end because he did go downhill very quickly. but it was really just about allowing him to call the shots at the beginning so that he could gain trust. Because it's it is not veteran specific. It's it's a control issue to allow somebody to come into your home and say,

You can't do that anymore. And so instead of making it about what you can't do, tell me what you can do or tell me what it would be easier if you didn't have to do this, right? I don't want to bend over and feed my cat because I get dizzy when I do that or whatever it is. And so we just adapt to to him specifically, but to all the veterans that we've taken care of. What do they need? Let's meet them where they are now.

And let's reevaluate over the next sixty days and see what's changed.

Miriam Allred (22:05)
And he identify it sounds like he identified his granddaughter. Is that a part

Megan Casey (22:09)
He did.

Miriam Allred (22:09)
of your process to help them identify someone in specific states or in kind of like the specific parameters when there can be family or friend caregivers? Is that part of your process to help them identify someone that they might feel more comfortable coming in and helping with their care?

Megan Casey (22:25)
Absolutely. If that's something that they want, right? And and especially in rural areas, if you have a town of 400 people, they're likely going to know the caregiver, whether you've identified them or they've identified them. And so when it makes sense and that caregiver can provide the level of care that they're needing at the moment, absolutely. Do you have somebody that you go to church with or that you know from the community center or that you know?

you through your veterans group that you'd like to be your caregiver. And maybe they work for now and maybe they don't work forever. but yeah, it it's gonna help them accept care. Let's do that.

Miriam Allred (23:04)
Yeah, because you mentioned this word like resistance, which is universal, but with veterans specifically, there is this pride, this stubbornness, this control, this independence.

Megan Casey (23:16)
Absolutely.

Miriam Allred (23:17)
Talk about how you break that down. Like how do you start to chip away at that? Like what specifically do you say or do to peel back those layers because their walls are can be so high at the start.

Megan Casey (23:30)
Absolutely.

I and I think if if their walls weren't high, I would be concerned, right? This is a veteran. This is somebody who wore a superhero cape and ran to the front lines. And now you're asking them to take off that cape and allow somebody to help them take a shower or to help them with toileting. That's that's big. That's that's a big pride to get around. And so I think instead of

Instead of changing their identity, work with them. What what can we do today? Or what could the caregiver do to make it easier for you? Right. And we talk a lot about caregiver training and making sure that the caregivers understand veterans and understand that pride and understand the walls that might be up when they walk into a home. So walking into the home respectfully, announcing themselves.

Not sneaking up on veterans. A lot of veterans have PTSC. You definitely don't want to sneak up on them. asking them if it's okay that you do something first. You don't want to walk in and move things around in the kitchen, especially if they live alone, right? They they have control, they know exactly where that flashlight has been for the last however long. And if a caregiver moves it, they're going to be upset. so I think less so in in asking them to put the pride away and

More so in figuring out a route around it to get them to trust a caregiver. I just recall this other veteran who was an amputee. And he said, Can you find me a veteran to take care of me so that I have somebody to talk to, somebody that I can connect with? And I was like, Yeah, absolutely. Two weeks later, he's like, Could you find me a veteran who's also an amputeeist? Well, now we're getting really specific. I don't know if I can go that way.

far, but I can definitely find you another veteran. And we did find him a veteran and he was thrilled. And it having that camaraderie and and him being willing to let somebody help him take a shower or help him get dressed or help him put his prosthetic on, that's a big deal.

Miriam Allred (25:46)
Yeah. Wow. What a what a great story of yeah, veterans taking care of veterans. Because yeah, seniors tend to want someone that can like relate and speak their same

Megan Casey (25:55)
Yes.

Miriam Allred (25:55)
language. Oftentimes that's just not feasible with the workforce and the supply and demand issue, but they want someone that they can, you know, banter with and that can resonate with

Megan Casey (26:04)
Yes.

Miriam Allred (26:05)
their experience and especially their lived in experience. Like they want someone that can relate to that.

You're already talking about, you know, like the caregiver and the expectation setting. It seems like that's that's a two-way street, expectation setting with with the veteran, you know, like here's what we can and can't do, here's what care looks like, et cetera. And then the same thing on the caregiver side. There's a lot of just like expectation setting. again, this might be kind of a universal concept, but does that ever surprise them? Like what can and can't be done in the home? And do they tend to

over ask for things or under ask for things because they're not aware, like what does that dynamic look like?

Megan Casey (26:43)
Yeah, they definitely tend to over ask, especially after they get comfortable, right? If you have you, you know, the same caregiver coming to your house twelve hours a week, you're gonna get really comfortable. And and we've definitely had situations where like, well, they asked me to make a full Thanksgiving meal, and I didn't want to say no. So I did it for them and their whole family. Whatever, you know, he wanted to have the Thanksgiving meal. Cool. I love that. and that specifically happened.

But other times, sometimes the the lines just get blurred because they have that communicative relationship. They they form a friendship. And it's good that they form a friendship. But we do set those boundaries early. And we have a lot of veterans who are like, well, I would never do that. And you might think that might never happen, but when you get a year down the road and that same caregiver's been there every day, sometimes those lines get blurred. So let's talk about it now. They're not gonna do your pet.

care. They're not gonna drive you to the casino. They're not going to, you know, do a full clean out of your fridge and scrub it top to bottom. That's not what the care is for. There's limitations to the program.

Miriam Allred (27:50)
Okay. Can you go one more level extreme? I heard you talk about this offline and hopefully you're comfortable talking about this online. I don't know if you know what I'm referring to, but there can be habits, bad habits, habit. I don't know if I should say bad habits, habits in general of drinking and drugs and turning to, you know, devices to help them with their PTSD. That is something that is maybe unique to veterans care, is just

the complexity of how they're coping and how you as the professional healthcare provider, how you have to set expectations and have that conversation early and often. Can you talk about how you've

Megan Casey (28:30)
Yeah.

Miriam Allred (28:30)
navigated that?

Megan Casey (28:31)
Absolutely. I I think it's it's really addiction and self self-medicating. And I don't know that it's veteran bes specific, but we do see it more prevalently in the veteran community. especially as the years have gone on. I remember starting in home care and I I don't think I ever had something like that happen, but over the years we've definitely had situations with alcohol, drugs.

Weapons in the home, you know, veterans choosing how they want to live, even if that's not the way I would want to live. And and so around self-neglect, right? Is the home clean? Is there rodents in it? And so we have a conversation with caregivers before they start that hey, this is the veterans' home. This is how they choose to live. There might be drugs and alcohol in the home.

You are the eyes and ears in the home. If if they're using it responsibly, and that's this is their home. They get to choose how they want to live. but you have a responsibility to notify us if something is extreme. And you have a responsibility to not partake in drugs and alcohol with the veteran, because right, that's that's a risk as well. and in in that we we do talk to the veteran about.

Putting away your weapons, not drinking, not smoking, not I g I so many things while the caregiver is in the home, so that you can respect the caregiver. A lot of caregivers, a lot of people that get into caregivers are young women. And when you're sending them into a strange home, and maybe somebody's drunk or there's paraphernalia on the table.

that can be uncomfortable with for them. So we talk about making a safe environment for the caregiver to the veteran as well. and and does it always work? No, no. But one of the first things that I always say when somebody brings me a situation like this is it's the veterans home. They get to decide if this is how they want to live. We get to decide if it's a safe environment for us to provide care in.

Miriam Allred (30:46)
Yeah, that's really complicated. That's that's like so complicated of just because I agree, you have to respect the home and the veteran and their way of life. But then also as the professional employer, the safety and well-being of your caregiver is also of up utmost priority. And you are the intermediary to strike that balance. That's really

Megan Casey (31:06)
Yes.

Miriam Allred (31:07)
complicated. But it sounds like you define those expectations and you create those policies and then you have the feedback loops.

To make sure that both parties are taken care of and safe and healthy and happy and that's all you can do. Granted things go wrong and there's extreme cases, but you just kind of do everything you can to put processes in place to protect both parties.

Megan Casey (31:29)
Absolutely.

And a a lot of the training that caregivers go through is not just about identifying you know, alcoholism or or drug use. It's about I identifying risks for the veterans. So self-isolation risks around the holiday, suicidal ideation risks, you know, have has anything changed for them? Did they stop eating? Are they spending all their money? Are they trusting somebody that they shouldn't be trusting? And it's about creating little advocates in the field.

so that they can report back so that the office and and the agency can report back to the VA or to APS or to the family and say, hey, this is what happened. This is what we need to do. This is what we think we should do. and and making sure that the veteran gets the care that they need. but suicide risk, especially as holidays approach or anniversaries or birthdays, it's a huge risk in the in the veteran community. And so

agencies should do a lot of training around that and a lot of assessment tools and and reassessment tools and checking in with the veterans and checking in with the caregivers and making sure that everybody knows what to be looking for.

Miriam Allred (32:36)
What about on the actual client side with kind of like the suicide prevention conversation? Obviously that's taboo, but

Megan Casey (32:43)
Mm-hmm.

Miriam Allred (32:44)
you again, as a professional, knowing those numbers and that likelihood and those like kind of scenarios, do you talk? granted, you train the caregivers to be, you know, watching for those signs and signals and all of that stuff. But what about making that more of an open dialogue with the with the with the vet themselves and their family? Do you ever

Talk about that openly?

Megan Casey (33:08)
Yeah, a lot of VAs actually require that any agency providing care talks about it at assessment and leaves a handout in the home of who to call, what to do if you're having these thoughts. And over the years I've gotten many calls to my phone of hey, I'm having these thoughts, or hey, my client is having these thoughts, or hey, my neighbor is having these thoughts. What do we do? and it's all about calling the veterans help hotline and and asking for help or calling nine one one.

and asking for help if it's imminent. But a lot of VAs have started requiring that form. I I think all the VAs should require that form and I don't know if it's looked at, but it should be.

Miriam Allred (33:47)
Wow. And that's another layer for you as the agency to educate yourselves, but also have that conversation. That conversation is not easy for anyone to have under any circumstances, but you

Megan Casey (33:59)
No.

Miriam Allred (33:59)
to have the confidence and the ability to go in and educate and have that conversation during the assessment. That's just like one more layer of education and confidence that you have to have. I didn't I didn't know that, you know, so that it sounds like some states mandate that you do that.

Megan Casey (34:14)
Yeah, absolutely. It's VA specific. there's you know a running joke that if you know one VA, you know one VA. And that is so true. And I I cringe every time I hear somebody say it, but it's so true. so you know, there's however many VAs in Texas, there's one VA in Texas that requires that form. And so, you know, when you're getting out there as an agency and and building these relationships, learn the rules of your local VAMC. But it's okay to go up.

And beyond those rules. It's okay to hand that form out, even if your VA doesn't require it, because you have to be comfortable having conversations around suicidal ideation and suicidal risk and have a plan as an agency of what you're going to do. And what you're going to do after an attempt or after a phone call, offering therapy to your caregivers, to your office staff, offering somebody to talk to, because it's heavy.

Miriam Allred (35:07)
Yeah. You've cited like a number of conditions, like chronic conditions or illnesses, amputees, Parkinson's, lung cancer, et cetera. We talk obviously a lot about Alzheimer's and dementia, like holistically, as just like a an aging population. With veterans specifically, would you say you could identify five or so like most common conditions or illnesses, or is it really kind of the full gamut that we would see in just senior care in general?

Megan Casey (35:35)
I think it used to be a little bit more specific ALS Parkinson's cancer. It's the full gamut now. We see pretty much everything, esophageal cancer. a lot of, you know, you see the the infomercials late at night. Like if you were exposed to this one during your time in Vietnam, you could have this.

Unfortunately, we see a lot of those things like the esophageal cancer or the brain cancer or something from exposure during their time in the military. so it but it it's really the full gamut at this point, depending on where they are in their aging process.

Miriam Allred (36:14)
And the other so then your part in that is just being educated on that, which is tricky because you're personal care, you're not necessarily like healthcare doctors or prescribing or diagnosing, but you have to know those things. How do you strike that balance of knowing what's in your lane as a provider versus okay,

Megan Casey (36:31)
Yeah.

Miriam Allred (36:32)
like there's other professionals that step in for these conditions?

Megan Casey (36:36)
The VA does a great job of outlining what the conditions are and what the the care plan includes for the personal care team. So you're gonna know that veteran's full medical history, even if they choose not to give it to you. Because if you've ever walked into an assessment with anybody, not just a veteran, and you say, So tell me what are your diagnoses, you're gonna get one. And then your authorization is gonna show two pages of very vivid diagnosis that you

didn't know until you read about it. But the VA does a really good job of managing that care. Those social workers work really hard at making sure that the skilled agency has those medical concerns and that the agencies know about each other. So when you get a call from VA Social World, you'll say hospice is involved or home health is involved or dialysis involved or the home-based community care, the home-based primary care program through the VA. So they have this nurse and you can call them there.

They do a great job of giving you all those contacts so so that an agency as a non medical provider can stay in their lane.

Miriam Allred (37:41)
And then back to kind of the caregiver training piece, you see and understand all these diagnoses and common conditions and illnesses, and then you can kind of build and tailor your training of your caregivers to those conditions. Granted, they still have what they can and can't do, but you want them to be educated on different conditions and diagnoses so that they can help the veteran to the best of their ability.

Megan Casey (38:02)
Exactly. So how does that condition affect what you can do with personal care? Can you enhance it with nutrition and dietary needs? Can you enhance it with redirection? What should you expect as the disease progresses? What's normal? What's not normal? What deserves a phone call to the office? and so without trying to create, you know, thousands of nurses in the field, create thousands of caregivers who've got some education under their belt.

And and you're gonna have a better caregiver workforce.

Miriam Allred (38:33)
Yeah. back to kind of talking about the family involvement, how often is the family a a hindrance versus a help? You know, that's again, that's kind of a universal concept, but with a veteran specifically, are are you fighting the battle with the family as well? Or do you find more often than that not that the family is actually on your side and is helpful in these conversations?

Megan Casey (39:01)
It's

probably 50-50 there too. And I think all families want to be helpful. And I think they probably all think they're being helpful. but sometimes what your loved one is telling you as a child is not the same thing that they're telling their caregiver or their agency, and that's where pride comes back in, right? So

I don't know that my grandfather would have ever told my parents that he couldn't do the things that he couldn't do, but he would tell his caregiver anything. And so I think families need to, like I said before, take a step back and remember to be the daughter and not try to be the case manager, the social worker, the caregiver, the care coordinator, the you don't have to know it all. You just have to love your parent or

grandparent or loved one through their aging process and let the experts do what the experts do.

Miriam Allred (40:01)
Yeah. And you have to get buy-in from both the family and the client. But I guess where I'm kind of like leaning is like with the veteran, granted, mentally they're still like capable and can make decisions and are like fully aware of and conscious of what's happening, getting the buy-in from the veteran is extremely important. Like I guess I could see in other cases where like you're almost just like selling to the family and convincing the family

Megan Casey (40:22)
Mm-hmm.

Miriam Allred (40:23)
and getting the buy in from the family. But with the veteran, like their acceptance and

their willingness seems maybe more important for some reason in my mind.

Megan Casey (40:35)
Absolutely.

Miriam Allred (40:36)
Like, do you know what I'm saying? Like it's always important to have

Megan Casey (40:38)
Absolutely.

Miriam Allred (40:39)
the buy in from the client, but with veterans specifically it feels like even more important.

Megan Casey (40:43)
Absolutely, because they will have no problem kicking somebody out of their home. And I don't blame them. but you you can use the family, you can do use context clues to figure out what's gonna make them tick, what's going to make them accept care, right? I've had many conversations with daughters and sons where they're like, if you send, you know, a really young female caregiver, he's gonna make an inappropriate joke. Or

if you send somebody that could cook this, that would be really great because the veterans really gonna love that. or somebody that has thick skin and will make jokes back. you know, using their experience to get acceptance is really meaningful. And sometimes we don't have that. Sometimes we just have to rely on the assessment, which is such a short snapshot of what the veteran's actually experiencing in their home, right? You're there for an hour.

And you walk out of there hoping that you're an expert on this veteran. You're not yet. but looking around the home, looking for pictures, looking in the fridge, looking in their bedroom. you know, are they a neat and organized person? Are they, do they have, you know, 500 TV dinners and you, you know, that's what they're eating. What what could I give them? And it's a sales approach, but what can I give them to make them want?

This service. and you've really got one shot when you have a veteran who's reluctant to care. You that first caregiver has to knock it out of the park, or you risk never being able to send another caregiver in there. And you're not just ruining it for your agency, you're ruining it for the veteran because if if your first caregiver doesn't show up, or they do a poor job, or they say something distasteful, or they they anger the veteran,

They're not gonna let another agency come in either. And now that veteran is going to suffer. So you have to knock it out of the park every time and do your research and don't just send a warm body into the home.

Miriam Allred (42:42)
Yeah. And it sounds like that assessment is so key. Like you've said a couple of times, like what makes them tick and like what their tells are. The assessment is your your chance to learn as much as possible. I'm curious, could you cite any specific like tells that they have of like, I guess I'm just thinking of like they say this, then you you know to say that, like, and you've learned that over years and years and years of conversations of like

they're all gonna say this line about like I don't need help, I'm independent, I could do this on my like they're gonna say these lines and then you know by default, like here's how I walk that back. Here's what I say to like, you know, peel back that that resistance. Like, can you think of specific things that they say and then how you what you say to like ease their concerns? Is it that formulaic?

Megan Casey (43:31)
I don't know that there's

Miriam Allred (43:33)
Yeah.

Megan Casey (43:34)
I don't know that there's anything specific. I've always just gone in trying to joke with them. Let me just go in there, try to make it fun, try to ask the questions. If you sit there with the assessment form in front of you and you verbatim ask question after question after question, you're not gonna understand who that veteran specifically is.

And so if you sit down without the paperwork in front of you and just have a conversation, have a good conversation, understand their life, understand what branch of the military did you serve in? What was your career? What did you do after the military? Tell me about your spouse. Tell me about your children. Tell me about your life. you know, did you watch the game last night? I, Miriam, I don't know a thing about sports. I have discussed so many sports with so many veterans.

Miriam Allred (44:19)
Ha ha ha

ha.

Megan Casey (44:21)
and and I will just wing it, just trying to get them to give me a little piece of something about their life. And talking about animals, a lot of veterans have dogs or just love their animals in general. And just find that little in, monopolize on it, and and use that to your advantage for their advantage, right? It's not about.

Winning as the agency, but winning for the veterans. So you've, you know, you left there, you've identified that they have, you know, a little terrier and they've had TV dinners for the last six months. They haven't taken a shower because they don't feel comfortable going in there alone, or they're not sleeping in their bed anymore because their spouse passed away and they don't want to be in there anymore. So you're not going to.

run in the next day and change everything, but you're gonna build a care plan around making that veteran comfortable in their home again. And maybe it's they're sleeping in the recliner for the next four months and you're starting to introduce family meals. Or maybe you're helping them prepare for a holiday without their family around. Or maybe you're helping them change the bedding and make the bedroom a familiar place again so that they're comfortable to go there. But you're

You're dealing with something so precious, and I joke about it a lot, but it is so precious to be allowed into this veteran's home to discuss their needs, their wants, their goals, their life. And you're you're being blessed with that. And I think people just need to stop.

and have the conversations and and put the forms down and see who they are as a person and then staff to that because you can't lose if you're doing it the right way.

Miriam Allred (46:18)
Yeah. And I love what stood out to me and all of that you just shared was so great. Was kind of like a lighthearted, almost like humorous approach. Like aging and long term care and senior care and all of this. It's really heavy. It's really,

Megan Casey (46:32)
It is.

Miriam Allred (46:33)
really heavy. And you saying this just reminds me of like a lot of the great providers in this industry that I think of, like, they're very upbeat. They're very smiley. They're very kind. They're very humorous.

And we even

Megan Casey (46:45)
Yes.

Miriam Allred (46:45)
talk about that. Like we have to have like kind of a sense of humor in senior care because it is serious and heavy and bleak and hard days and death. Like all of that is not foreign to us. And so you kinda have to have like that like lighthearted mentality and letting that show through to the families and the clients. Like granted, like right time, right space, like is appropriate,

Megan Casey (47:03)
Yes.

Miriam Allred (47:04)
but leading with like cheer and joy and positivity and humor is just a way to kind of like lighten the mood and open them up. I don't think anyone

would respond negatively to that. Like they they need kind of a sense of just like lightness in their life at that time.

Megan Casey (47:21)
Absolutely.

Often you're meeting them at the worst time in their life. They can't do these things for themselves anymore. And so you're not meeting this family on a great day. And they might have been waiting a while for you to get in. Sometimes veterans get wait listed. Sometimes the process takes longer than anybody wants it to. And so if you go in hopeful and cheerful and with a little bit of joy and

Spread that around because joy is free. let's spread it to everybody. you can change their experience and you can change their mindset around home care.

Miriam Allred (47:59)
Yeah. And one other thing that I wanted to circle back around to, you talked a little bit about hours and this is getting into the weeds a little bit, but usually they're

Megan Casey (48:04)
Yeah.

Miriam Allred (48:07)
assigned a certain amount of hours at the start, but then you reassess and reevaluate and their hours can go up or down. I'm guessing

Megan Casey (48:14)
Or tell.

Miriam Allred (48:15)
that's a big part of the conversation that you explain to them of like this is where we're starting and we can reevaluate.

I wanted you to address that a little bit more head on because that's a big part of this as well, especially if they need a lot of care but they're not starting with a lot of care. How you navigate that with them of like, This is just a starting point, we'll reevaluate and we'll kind of work through this together.

Megan Casey (48:36)
Yeah. So, and you can reevaluate it sooner than you think. If you get an authorization from the VA for six hours and you walk out of that assessment, knowing that six hours is not going to be safe for this veteran, you can call the VA right then and make the request. And you let the family know what you're doing. Have the family make a request as well because it's important that it's coming from the family and not just from the agency, right? Agency has

profit

to make by more hours. So the VA needs to know the family needs to know that you're doing it for the right reasons. You can also tell the family, tell the veteran, tell the caregiver, when things change, call me because we could send in an RFS, which is a request for service, and say, hey, this veteran's needs have changed. This is what has happened since our last assessment. We think they could benefit from some more hours or some more care. And then the VA does their own assessment.

With using the case mix tool to say yes or no. and and if it if they say yes, that new authorization comes to you very quickly and you can start providing more care. I've seen veterans get 85 hours a week of care. Is it regular? No, but it happens. So you should be asking for it.

Miriam Allred (49:50)
And we haven't talked about this a whole lot, but how often do they refuse? I'm guessing you've had experiences where they do refuse and it's not necessarily reflective of you, but there's reasons and circumstances where they refuse. How often have you had that happen?

Megan Casey (50:06)
Say probably 10% of the veterans that get referred end up refusing, and whether that's because it's just not the right time for them, or they're never going to allow somebody in their home, which happens, or the program wasn't explained very well to them before that first phone call came in. Which the VA is busy, these things do happen, and they were shocked that first day. But I would say 50% of them come back.

And say a couple months down the road, things have changed. Can I still get that care? And you just have to call back to the VA or and say, so and so reached out to me. They're ready for care now. Is this authorization still valid or can I get a new authorization? explain the benefits of the program and and people that really want to use it and that really need it will come back to you.

Miriam Allred (50:58)
And it's veteran's choice, correct? And that they choose. They can choose the agency. Granted, the veteran can assign out referrals

and they choose, but the veteran

Megan Casey (51:06)
Yeah,

Miriam Allred (51:08)
has the choice. And so reputation is extremely important. Granted, the veteran community, especially in cities, rural communities, is like very close and that they know each other. But talk a little

Megan Casey (51:18)
Absolutely.

Miriam Allred (51:18)
bit about just like how important your reputation is. We talk about first shift and training and just like all of the moving parts, but your reputation is so, so key and can be a huge

You know, momentum build over your success.

Megan Casey (51:30)
Absolutely. Veterans talk to other veterans and VA referral sources, the case managers, the social workers, they are going to call the agency that they know is going to take it and do a good job. And so your reputation in that community is everything. And that's another reason why you shouldn't push a veteran that's saying no. If they're saying no, stop, stop. If they really want the care, they'll come back. If you keep calling them and calling them and stopping by,

to leave a bad taste in their mouth, not specifically for home care, but for your agency. Give them space to make this decision and let them know if they're ready, they can call you back. And and and they usually do. but veteran word of mouth, you go to the VFW, like I said before, to the VSO, to the diner on Sunday morning. They're sitting there, they're talking. And when you do a good job, they're going to tell other people and you will get more referrals.

Miriam Allred (52:29)
Wow. And one of your approaches, you know, the last few years has been to take the hardest veteran cases out there. And I share that because everyone that's listening to this, now you're consulting, which was amazing. So people can tap into your knowledge and resources. And trust me, if you have any questions about veteran care, like Megan is your go-to. And we're talking about the service delivery, but your experience and knowledge on the

the associations and the networks. And like you said, there's if you know one, you know one. But like you know many. And so anyway, your connections and resources are vast. but you're consulting now. And so I just want to say to people listening to this, if you have questions, reach out to Megan, but also about really hard what what a provider may think is a one-off veteran case that they have. You have likely probably been through something like that. And so I want

To tee you up as just kind of like a resource to everyone listening to this of if you feel like you're hitting a wall with a client or with a family or with a scenario or with a, VA office, like Megan has maybe seen it all and done it all as much as anybody else has. And so, you know, utilize her as a resource. Megan, is there anything else that you can think of? I guess the questions that I haven't asked or things that you thought we should cover that I haven't mentioned. I feel like we've dialed through a lot of.

great concepts and you've told great stories. Anything else that I'm maybe missing that you wanna touch on?

Megan Casey (53:54)
No, I just think you know, everybody that's out there serving veterans or that wants to serve veterans, you should be so proud of what you're doing. I mean, this is such a needed service. And you are gonna be able to lay your head down at night and know that you helped somebody who truly needed it. And our country needs more of that. So just thank you for everybody that wants to do it and thank you for Miriam for letting me come talk about it.

Miriam Allred (54:23)
Yeah, the pleasure is mine. I think Momentum is so lucky to have you. So I cite that again here at the end. Megan is working as an executive consultant at Momentum Healthcare and Technology Consulting. And so she is, helping other providers and technology companies and all sorts of people just in the in the home care space to learn more about these things. And so I just I hope anyone and everyone reaches out to you that has questions.

But we'll go ahead and wrap here, Megan. Thank you so much for everything that you've shared today. Again, I I echo what you just said of There are so many people that need help. And that's all of our personal mission is just to help, you know, one more person, one more family get better care that they need. And so I'm grateful for everyone that's doing this work, including yourself. The impact that you've had and the impact that you're going to continue to make is just amazing. So thank you so much, Megan.

Megan Casey (55:09)
Thank you, Miriam. Thanks for having me.