Innovive Health Building In-Home Care Model Around the ‘Most Underserved Population in the Country’

Joe McDonough began his health care career in the hospital setting, mostly working with individuals with complex and chronic mental health conditions. After seeing so many of his patients return, he became determined to build a better care delivery model.

That’s exactly what he’s doing at Innovive Health, a Massachusetts-based home health provider with a truly unique patient population.

“It’s a much more challenging population than the traditional geriatric Medicare population that most home health agencies focus on,” McDonough told Home Health Care News during a recent HHCN+ TALKS appearance. “It’s really the most underserved population in the country, in my viewpoint.”

HHCN is pleased to share the recording and transcript of our HHCN+ TALKS conversation with Innovive Health CEO Joe McDonough. Read on to learn more about:

— How McDonough created a home health niche by focusing on an underserved patient population

— Why Innovive sees data and information sharing as the keys to its future

— What McDonough and his team are doing to recruit and retain in-home care clinicians

The below has been edited for length and clarity.

[00:00:06] Holly: Welcome, everyone. I’m Home Health Care News editor Bob Holly. You are tuned into our latest HHCN+ TALKS conversation. For the next 30 minutes or so, I’m chatting with Joe McDonough, CEO of Innovive Health, a home-based care provider based out of Massachusetts. We’ll get started with that in just a couple of minutes here. Before we do, I wanted to make note of a couple of things. First, this conversation is being recorded; all HHCN+ members will be able to rewatch this episode of TALKS or read over a transcript, whatever you prefer. All you have to do is go into your HHCN+ dashboard.

A quick reminder, before we dig into things: We do welcome questions. If you have something that you wanted to ask Joe or me, please use the question function in Zoom. You can submit questions at any time, and we’ll try to field as many as we can. Without further ado, I’d like to welcome Innovive Health’s Joe McDonough. Joe, thanks for being with us.

[00:01:24] McDonough: Great. Well, thank you very much for inviting me, Bob. This is exciting. I’m very happy to be here.

[00:01:29] Holly: It’s great to talk to you again. It has been a while since we connected on the podcast. Was that last year or in 2019? Time really flies these days.

[00:01:38] McDonough: It was in 2020, and I think we both looked better on the podcast actually.

[00:01:44] Holly: Yes. I can’t argue with you there. How’s everything going? Where are you joining us from today?

[00:01:51] McDonough: Well, I’m joining you from my home office in Woburn, Massachusetts. Where we are is where every other health care provider is: We’re struggling with staffing. Staffing is a priority for many health care organizations across the country right now.

But we’re doing very well. We’re focusing on our patient population. As you know, we’re in this COVID world where it’s permeating everything. We’re dealing with vaccine mandates. We’re dealing with personal protective equipment (PPE) challenges. Supply-chain issues are creeping down the pipeline. There’s just a lot going on. But we’re doing very well.

[00:02:28] Holly: Well, that’s good to hear. For your staffing point, we just covered Encompass Health’s earnings call. We’re speaking on Thursday, Oct. 28. They estimated that they had to turn down 2,500 or so home health referrals, I think, on the quarter. They simply didn’t have enough staff to take those cases. Before we dig into that issue further, there’s a lot of people on the call today who are tuning in later or on an on-demand basis who maybe haven’t heard of Innovive Health before. Could you maybe just recap the basic business, starting with the very beginning?

[00:03:07] McDonough: Sure. Innovive Health is a home health company. We specialize in working with patients who are chronically mentally ill, who have severe medical comorbidities. We’re just like any other home health VNA, but we focus on a younger population. This is a population that really has a high-acuity base. They’ve been in the hospital multiple times. They have a high ED utilization. We really focus on this population: a Medicaid, non-homebound population. It’s a much more challenging population than the traditional geriatric Medicare population that most home health agencies focus on. It’s really the most underserved population in the country, in my viewpoint.

We are probably the largest home health agency in Massachusetts at the moment. There’s a lot of wonderful home health agencies here, but we focus on this population. We’re really busy. We do probably close to 23,000 patient visits per week, which has been a challenge due to the staffing crisis. But we’ve been able to manage this population, and our nurses have done a wonderful job. The rest of our clinicians as well.

[00:04:25] Holly: Could you provide some examples of the services Innovive is delivering? Then you mentioned being the largest home health provider in Massachusetts. Could you just put a little bit more color around that?

[00:04:44] McDonough: We’re in most of Massachusetts, except for the extreme western part of the state and Cape Cod. We’ll probably be expanding into both areas. Our nurses really function as the hub of the wheel and the system. It’s a very fragmented system. Oftentimes, our patient is, say, a 55-year-old person diagnosed with schizophrenia and 10 other medical comorbidities.

They may have a primary care physician, a psychiatrist, as well as a diabetic specialist involved in their care. They may be working with the Department of Mental Health, so a caseworker could be involved. There could also be another department point person who oversees housing. It’s sometimes difficult to know everyone who’s involved. One hand doesn’t know what the other one is doing, and our nurses really act as the focal point for coordinating care across all the stakeholders in the spectrum.

[00:05:59] Holly: I imagine when you were getting Innovive Health up and running way back at the very beginning, you had a passion for home-based care. But how did this very specific focus evolve? Why not just be your generalist home health provider?

[00:06:15] McDonough: I started out working as a mental health worker in the hospital. I noticed a lot of times, it was a very challenging population. That was back in the early 90s. A lot of times, you would see the same people coming in and out of the ED, or in and out of the hospital. Oftentimes for this population, it’s not uncommon for them to be hospitalized up to 20 times a year. Once patients left the hospital, once they were out there on their own, there was nothing in place for them.

I noticed that, and I went to graduate school at Yale University for psychiatric nursing. I started working in Connecticut, which had a very well-developed psychiatric home care system. They really did a good job working with the population in underserved urban areas. That system did a great job keeping people out of the hospital.

I moved back up to Massachusetts, where I’m originally from. I moved up in the year 2000 and started this program. One of the things that I noticed is that even though Massachusetts is a very progressive state and has a very progressive Medicaid program, there was nothing in place for what we’re talking about. In the continuum itself, there was a huge gap. I noticed that gap, and that has been my passion. In less than 10 years, we became the largest home health company in Massachusetts.

[00:07:47] Holly: We now have a good idea of your origin story and some of the services that you provide. What about your revenue mix? What reimbursement streams does Innovive work with?

[00:08:12] McDonough: About 65% of our revenue is from traditional Medicaid, which is managed by MassHealth in Massachusetts. The rest is managed by Accountable Care Organizations (ACOs). We’ve been working very closely with a number of them. There’s a huge potential with ACOs partnering with organizations like ours to really help contain costs and create better outcomes for these patients.

[00:08:47] Holly: I was listening to a discussion with CMS Administrator Chiquita Brooks-LaSure and the director of CMMI. They made the comment that, over the next several years, they want every single Medicare-age beneficiary to be in an accountable care relationship. What’s your take on that?

[00:09:14] McDonough: I think if it’s implemented properly, it’s a great thing. As a function of traditional managed care, I don’t think we’ve really taken advantage of all the opportunities to improve patients’ quality of life and shift care into the lowest-cost setting. This isn’t my particular area of expertise, but I think anytime you hold all providers accountable and put them at risk, that’s a good thing.

[00:09:50] Holly: We’ve, especially recently, reported on how payers like Humana, Anthem and others are trying to shift more care into the home. We’re also reporting on the Biden administration’s attempts to shift more care into the home. How do you see those things impacting your revenue mix moving forward? Do you think it’s going to stay pretty static or do you expect it to change at all?

[00:10:21] McDonough: I expect it to change. As ACOs start working with this population, they’re going to start looking at different things. Clearly, social determinants amongst this population is a huge issue. If somebody is diabetic, for instance, do they have the right types of food in their refrigerator? Do they have enough supplies in their home? Is their home clean? Do they have syringes on their floor and that sort of thing?

That’s a huge area of opportunity for ACOs. The other area of opportunity for ACOs for the most vulnerable patients is having more primary care opportunities within the home, utilizing PAs or nurse practitioners to do home visits in conjunction with organizations such as Innovive.

Particularly for our population, they may only get seen by a primary care physician maybe a half-hour per year, in two 15-minute increments that are six months apart. These patients are not good self-reporters. And frankly, it’s not a very efficient thing to try to organize a ride or get them to drive a half-hour into the city to see their primary care physician. Frankly, it would be better for us, with the technology available. We could have all the clinical stakeholders on a Zoom call in the home, along with a physician assistant or a nurse practitioner. We think we could create a much smoother communication across all the stakeholders.

[00:12:03] Holly: Your traditional Medicaid or Medicare home health operator, they sometimes have that family support system to rely on to maybe help with things like social determinants of health, making sure that their loved one has a refrigerator that’s stocked. Do you have that family support system as well, or is it sometimes more challenging with this patient population?

[00:12:33] McDonough: In some cases, we do have a lot of family support for the population. But those are patients that we’re not really working with. We really focus on the patients who are the most vulnerable or the most at risk for rehospitalizations and ED usage. A lot of these patients, unfortunately, don’t have family support. Perhaps they’ve burnt out some of their families, so they don’t have families available to them. I always tell people we probably do about 2,500 patient visits every Christmas. Oftentimes, our clinician is the only person that patient may see that day.

[00:13:15] Holly: All right. Let’s dig into some of the biggest challenges that you’re currently working through because I’m sure it’s a fairly long list. When we’re talking about traditional home health agencies, staffing is at the very top. What are your two or three big topics right now and why?

[00:13:44] McDonough: Our primary topic at the moment is staffing. I think that has long been a crisis, and there are multiple reasons for that. We have a lot of clinicians who work very hard. They’re very dedicated to the population, but they simply are getting burnt out. I think that has been a challenge for all. My colleagues who work in hospitals or other home health providers are dealing with the same things.

We’re paying a lot of attention to our internal culture, paying a lot of attention to providing more positions of support for our providers. We really have to find creative recruitment strategies to try to mitigate some of the internal challenges that we’re facing. As far as some of the other challenges, providing care in a COVID environment with vaccine mandates, which we support, is certainly a challenge. We know of some people and of some clinicians in the industry who feel strongly about not getting [the vaccine].

That’s something that we’re really working around to be able to continue to provide seamless care for our patients. I think, for the most part, most of our clinicians are vaccinated, so that shouldn’t be too much of a stress for us.

[00:15:04] Holly: What does the workforce itself look like as far as discipline mix?

[00:15:09] McDonough: We have about 750 employees, most of them are nurses, RNs. We have probably 10% of that who are LPNs. Then as for the rest, we have physical therapists and some occupational therapists as well.

[00:15:27] Holly: You mentioned creative recruiting strategies to find more in-home care professionals. What’s an example of a creative recruiting tactic that you’ve had to take?

[00:15:39] McDonough: We’ve utilized technology to create virtual orientations. We’ve had to be very flexible with the way we onboard and find new employees, certainly utilizing social media, whether it’s Facebook groups, Twitter, LinkedIn or other modalities for recruitment. We’re trying to look at different ways to provide bonus structures to attract nurses. It’s such a challenging group right now — everybody wants the same people.

[00:16:33] Holly: I know the COVID-19 pandemic has made the staffing situation even tougher, but have there been any silver linings to it? Have more nurses who traditionally operated in the hospital, for example, become more aware that the home is a place where they can make a career?

[00:16:52] McDonough: I think we’re seeing some of that, but it’s hard to tell exactly what the trend is at this moment because there’s such fluidity with a lot of the changes. We have a lot of nurses that have been with us for a long time, who really are dedicated to the population

[00:17:28] Holly: As far as other challenges or important topics on your radar, we’re expecting CMS to release some guidance on the vaccination policies coming from the federal government in the not too distant future here. Has that been a huge topic for you?

[00:17:49] McDonough: We’re certainly curious to see what the federal guidelines are going to be.

[00:17:54] Holly: Massachusetts has some state-level ones, too, correct?

[00:17:58] McDonough Yes. The Department of Public Health in Massachusetts has implemented guidelines for home health agencies. We’re following that. We’ve been working very closely with our staff over the last month to make sure that we have the most up-to-date vaccine status of all of our clinicians.

[00:18:24] Holly: Any other key challenges that you’d like to highlight before we move on to some of these other questions?

[00:18:31] McDonough: Challenges at the moment or in the future?

[00:18:41] Holly: Are there any other present challenges that you think are important to touch on?

[00:18:52] McDonough: As we start working closer with accountable care organizations, we need to be better at being able to share data back and forth, to really understand what’s driving some of these negative outcomes so that we can create better treatment plans to help them save money and keep patients out of the hospital. That’s a challenge at the moment.

[00:19:32] Holly: What about long-term challenges? Are those any different than the few you’ve touched on already?

[00:19:38] McDonough: I look at them more as long-term opportunities. I think there’s a huge opportunity, again, to start to utilize us in a different way, to help usher in more primary care, to understand social determinants and what drives negative outcomes for this population.

I think we can start utilizing technology and understanding data more. We can enable data sharing across the spectrum with all the other clinical stakeholders to provide much better seamless care for this population. I think a lot of the things that we’re doing in Massachusetts we’re going to be able to do across the country. There are several states that we think would be very amenable to this type of service.

[00:20:33] Holly: That really tees up this next question that I have. This is something you told HHCN a while back: “We still have a long way to go — and the industry especially has a long way to go — to really be able to collect and aggregate effective data to improve outcomes. One of the hurdles we face is really trying to be able to share data with payer sources to fully understand the continuum of what these patients face.”

That’s exactly what you were just talking about, so maybe could you walk me through how you at Innovive are tackling that issue?

[00:21:27] McDonough: We’re cloud-based. We worked very hard the past few years in 2018 and 2019 to make sure that we were cloud-based as an organization. In the spring of 2020, when COVID hit, we had a seamless transition. We were able to have all of our support staff, all of our intake department, all of our insurance departments and all of our scheduling and support for our clinicians offsite within a week. We were one of the few agencies in Massachusetts, from what I understand, that never missed a visit all through the COVID pandemic.

We spent a lot of time working on that. As far as leveraging technology, we’re utilizing Salesforce for our intake process. We’re probably the only home health agency in the country utilizing Salesforce for the chronically mentally ill population for intake. We’re aggregating a lot of different data or research. We’re certainly understanding much more about hospitalization and ED usage patterns with that population.

As I stated earlier, at the moment, we do 23,000 patient visits per week. Imagine, if we could get nine data points per visit to understand this population, you’re talking about over 9 million data points within a year. That’s an exciting thing for us.

[00:23:42] Holly: That really helps paint a picture of the degree of this challenge. That’s obviously a ton of data to make sense of.

[00:24:06] McDonough: It’s a new frontier for this population, and we are on the vanguard of that. That’s what I’m excited about. I think we can really, really make a huge difference in this population and how they’re cared for in this country. I appreciate you giving me the forum to talk about that because I think this is a group that is tremendously underserved. The system simply is not set up to really provide for their true care needs.

[00:25:00] Holly: Do you anticipate seeing more organizations like Innovive popping up across the country?

[00:25:11] McDonough: Now, there’s not many people like us. I do think at some point you will see it. I think that the need is there. We welcome more people getting into it. For us, it’s a passion. It’s our calling as an organization to improve outcomes and save costs throughout the system.

[00:25:52] Holly: Well, we’re going to start wrapping up here in the next 5 minutes or so. Looking ahead at the next 12 months, what can we expect?

[00:26:03] McDonough: Well, we’re certainly at this point looking at opportunities nationally. We’re looking at and having conversations with several states about what their needs are. If we talk again a year from now, I anticipate being at least in one or two more states. The need is national. I think we are going to have a mental health epidemic in this country. I think that the need is going to be huge. I think it’s going to overwhelm the system. Certainly, this country needs more of Innovive.

[00:26:39] Holly: There are two huge areas that private equity firms are interested in right now. One is home-based care. One is mental health or behavioral health. You’re right at the intersection of the two. Is that something you’re interested in, or have you seen interest from PE firms looking to back companies like Innovive?

[00:27:01] McDonough: Sure. Well, there’s certainly a lot of interest out there. Private equity companies are certainly tuned in now to really what the needs are in the community and what the opportunities are. Certainly from an advisor’s perspective, we are always looking for people to partner with, whether they’re providers or capital sources. But it has to be the right partner.