This article is sponsored by Ava. This article is based on a discussion with Victor Hunt, CEO at Ava, Kunu Kaushal, CEO at Senior Solutions, and Michael Slupecki, Chief Executive Officer at Griswold Home Care. This discussion took place on August 22, 2024 during the HHCN FUTURE Conference. The article below has been edited for length and clarity.
Home Health Care News: Every year we hear that turnover in home care is a major challenge. The latest benchmarking report puts the average turnover in home care at nearly 80%. Even with COVID programs having ended and turnover remains this huge issue, in your experience, what are some of the main reasons that providers continue to struggle?
Victor Hunt: First, we always hear this number, 80% thrown around. The big thing for us is really taking a look at where is that coming from? How do we actually talk about turnover in an intelligent way, segment that out because there’s turnover that we’re just never going to win those folks back, the non-preventables. Those folks who maybe caregiving isn’t the right industry for them, but we really like to focus on preventable turnover, those folks who are leaving and going to another agency. These are the people who we really want to zero in on and understand what is it that’s breaking the relationship and why is it that we’re not catching this soon enough to actually address the root because and bring these people back into the fold.
We see this all the time where a lot of folks start off and have an incredibly high turnover. When you really dig into it, it’s no surprise, it’s no mystery. Scheduling is the big issue. Caregivers are here to work. They love what they do, and they want to work. They want a schedule that works for them. They want a patient. They want a client who’s a good fit. The challenge is how do you establish that relationship where you can understand that the client they have is actually someone who’s a fit that’s not going to because they want to go and look for that next shift at the agency up the street.
Alternatively, you’ve got plenty of folks who are fighting these three front wars. You have new clients and existing clients that you’re working with. You have recruiting and you have your existing caregivers. How do you make the time to actually understand is this caregiver enjoying the world they’re in and do I have a good grasp on those caregivers who don’t have an actual good shift. Someone who has been onboarded but for two weeks hasn’t had an update on when they’re getting scheduled, it’s no surprise why these caregivers will leave. The challenge comes down to how do you give that back office, how do you give that staff the ability, the tools to scale, so that they can find those issues and get to them quickly.
Kunu Kaushal: I’d say we’re a bit more controversial. We actually enjoy turnover. We’re digging for gold. We look at caregivers as an opportunity for figuring out who the good ones are. You have to be open to the applications. You have to let them come in through the door. For us, we are not as scared of turnover as some organizations are. I think we look at it as, we’re going to find a diamond somewhere in the rough. Years ago, I would tell you we were far more obsessed with the idea of that number, let’s call it pre-COVID, but at that time, you were looking for that skilled caregiver, that caregiver that had been in the industry for a long time.
What we’re finding just with population growth, the demand growth, we’re not having to build caregivers. We’re having to find more diversified caregivers that come from backgrounds that are not, you used to be in the nursing facility or you used to be in assisted living. For us, the reward and recognition, the training emphasis is much higher. We look at it as, if you take 100 shots, if we can get five, 10, 20% of those to work out, because our training was really good or our reward and recognition program was really good, we’re still winning.
At some point you also have to realize the capability of we’re hoping we introduce caregiving to a lot of people that have not seen what caregiving can be. The fact that we’re not a sitter service, that we are not this antiquated model of what caregiving was and introduce them potentially to the healthcare world in general. We have turnover, and it’s okay. We wear it with some pride. We look at the successful caregivers that after 30, 60, 90 days, six months, a year, and we look at them and their profiles and say, “What were you doing before this?” They say, “Well, I used to drive for Amazon,” or “I was looking for a career change and I found home care and I love it.” Those are our wins.
Mike Slupecki: I like what both of them had to say. I think we always viewed it too, as a scheduling challenge from a convenience location versus where they live, those types of things. The other thing too, is when you’re going through the number of caregivers that we’re going through due to this turnover. Our teams are really hesitant to give a brand-new caregiver a 40-hour shift. They have no experience working with it that you’re afraid of, are they even going to show up on their first shift? Some of those people you lose in the first 90 days are because you’re still testing them out, trying to dig for that gold, like you said, Kunu.
It’s really, how do you give them what they want? Because if you give them a 10-hour shift, they’re still looking for another 30 hours in many cases. If somebody finds a better opportunity at another competing agency, then you could lose out on a good caregiver. It’s like any problem that we deal with, there’s 100 things that go into solving it, and addressing the rewards and retention was one thing that we did to impact that as well. It’s never one thing, and it’s never a silver bullet.
HHCN: Obviously turnover creates significant cost for the business in terms of recruiting expenses. I wanted to hear about some of the other impacts of high turnover for home care providers.
Hunt: I think one of the things that everyone here recognizes is the value of reputation. This is a very insular space. Everyone in this room has a reputation. The more we go to these conferences, the better we get to know each other. This is also true on the local level with caregivers. An agency that has a high turnover rate, has a hard problem keeping caregivers, that reputation speaks volumes in those communities. We see this time and again. A family caregiver leaves, you lose the patient too. What about that caregiver who left and they made three referrals?
Those people are thinking about their cousin who brought them into the agency and now they’re thinking, “Hey, should I still or should I go join Betty at the agency up the street?” Reputation has a huge impact. The way you treat those folks, even if they are leaving, there’s turnover that’s good turnover, but it’s the way you treat people on the way out that’s going to lead to those net promoters who are going to bring folks back in even when they’re not working with your team.
Kaushal: I would say one of the downsides is clearly the HR department is very frustrated. From our perspective, what we say is you need to go out and hire 15 to 20 people a week per recruiter in our model. For them, they understand the burden of that. They understand how much work goes into that level of work. From our side, we just try to focus on the efficiency of it. The reality is if we can make hiring 20 people the same amount of work that it feels like to hire two, you’re going to do that work. If through reward and recognition and training you can have higher retention and you can get the gold to come up to the surface, they also feel very successful when that type of thing happens. I would say it’s a short-term challenge. I think there is a ripple effect that happens where, yes, there’s a monetary expense.
If you apply the same tactics of sales and marketing to recruitment and hiring, what you’ll find is none of us would ever say, we want less people calling the business. We want less in-home assessments. That’s also work, but you want a shot at trying to see if something actually comes to fruition with that.
Slupecki: Yes, I think we all know the value to our clients of consistency. They want to see the same face. That’s so critical. The other piece is the client satisfaction side by having the continuity of care, the familiarity with the caregiver that they’ve been using. Yes, it’s reputation, but it’s reputation from both the caregiver side as well as the client side.
HHCN: I want to know, overall, is this a lost cause? What I mean by that is turnover just, a fact of business?
Slupecki: Yes, I think it really is. Again, I think I love what Kunu is saying about trying to find that goal because you do have folks that are just trying to try out a new career and it’s a fit or it’s not a fit, and it’s such a balancing game. When you have eight great caregivers, the phone hasn’t rung for new clients. Then by the time the clients come in, those eight have found another job. There’s a lot of that that’s going on as well. You’re always trying to balance the perfect amount of staff to caregivers. I think it’s really about, yes, we do look at retention.
We do look at average tenure of the caregivers to think that we’re, at least the ones we got, they’re growing with us and staying with us. Those are different metrics than just the turnover. I think everybody has that magic 90 days. I don’t think we’ve overemphasized that because there’s so many things that go into that. I think it’s really the ones that you have, keep them engaged, keep them on board, and keep them working. Then again, try to find the new ones. I’m going to probably steal his lingo over here.
Hunt: It really depends if this is a lost cause. If you’re an agency with 20 caregivers and your goal is to stay at the 20 caregiver mark, there’s no issue with retention. All those folks’ names. You can address these issues. Immediately, you’re responding to text messages. If you’re like most folks in this room and like most folks who are providers today, you want to break past that inflection point of being a small business and become, like most of the folks in this room, a growing enterprise that can actually scale to hundreds, if not thousands, of caregivers.
At that scale, where this becomes a loss is if we’re still trying to do things manually, the old way, like we were when we were 20 caregivers. You’ve got to go give your staff those tools that are going to make, hiring 20 people feel like hiring two people, where you’re going to be able to perform that culture at scale, reach out to those caregivers, and show them that their potential and that they can be engaged in showing you everything that they can bring to the table so that they can actually get those 40 hours that they’re seeking. That’s where we see this being the difference in folks who have a growth mindset versus those who are focused on, we want to do things the old way. That’s where it becomes lost.
Kaushal: I would just say our focus is to do the best that we can, be as efficient as you possibly can, but also welcome home care. Caregivers are going to call out of shifts. Caregivers that were great at one period of time in their life, something changes for them, and now all of a sudden they can’t work those shifts. The caregiver that wasn’t doing a great job all of a sudden gets some training and coaching and gets with a client that they really like, and they are some of the most dedicated people that you’ve ever met to that client. I don’t know about lost cause as much as just accepting this is the game, per se.
Being more efficient and effective though, I think rewards and recognition, what we’re finding is that certainly as an organization, we are doing a far better job around retention, reward and recognition today, literally today, than we were six months or a year ago. I think a lot of that has changed partially because of the technology that we’ve brought in. Let’s be honest too, we as an industry have raised our prices, we have gotten more funding through Medicaid programs, if that’s how it came through, and caregivers are also being valued more than they were as well. You had a segment of caregivers who left to go do something else purely because they were getting better pay.
I think that paradigm will continue to be a pressure. As we continue to bring up their value, their joy in doing home care, that you will see more of them come to us and gravitate towards the industry.
HHCN: I want to talk about best practices that work. What are some existing best practices that have had an impact on turnover?
Kaushal: As we’ve introduced Ava, one of the biggest things that we found as a limiter was the human behavior element of our schedulers, our HR department, our people in the office. The fact is, if you ever want to see when the effort goes away from your business, it’s probably the first hour or two in the morning. It’s also around three o’clock in the afternoon, and all of a sudden we’re not as excited about doing all the work that we need to do. Why? Because people are burned out. We’re asking them to do more with less.
For us, I would say the biggest thing has been automation, some level of very quick response from a reward and recognition standpoint. The caregivers, at the end of the day, want the reward and recognition. They don’t necessarily need to know somebody spent five hours pulling six spreadsheets to figure out that they’re the one that should be recognized. I would say the biggest improvement that we’ve seen really happen is the fact that in their app, through automated messaging, other things, when they do good things, we as an organization, our brand, is saying thank you for all of your hard work. We’re also making it dynamic to them. I think we’ve all had caregiver of the month. If somebody introduces caregiver of the month as a good idea, today we’d all go, okay, we’ve been hearing this from the dawn of time.
The other side of this goes, we have caregiver of the day. With technology, you could go, I was the best caregiver based on metrics in maybe my office or my region. This month, I’ve been automatically looked at for many other reasons other than I’m the favorite by the scheduling coordinator.
HHCN: Victor, you work really closely with a lot of these home care organizations. What are some best practices you’ve seen work?
Hunt: Yes, absolutely. I think that my favorite part about what we’re doing is that we got to work with amazing operators like Kunu and Mike here. They really understand what’s working for their business is often very bespoke to their business. When we look at things that Griswold is doing that are working, those practices make a ton of sense in their context versus, say, Kunu’s agency. They’re going to be different things that work for them, but they can adapt and piggyback on some of those ideas. One story that comes to mind is, take Griswold for instance. We had an example where when we started early on working with their team, we understood that they had a set of best practices for how we engage a caregiver to understand what are those breakpoints that often lead to a turnover.
One example is, does this person have enough PPE to go and actually take care of their clients or are they going in unprepared? There was a weekend caregiver who reported through Ava, “Hey, I’m spending out of pocket on PPE because I can’t get into the office during the week, I’ve got to take my kids to school, I’ve got this other job that I’m going into, I can’t make it to actually pick up the PPE you provide.” That message went to the Griswold director who then responded immediately, “Hey, tell us your Availability, we’ll leave the office open later. This way you can come in and get what you need and not have to spend out of pocket.”
That caregiver is still here with Griswold to this day. These are small examples that compound. Without that level of engagement, this team would be in the dark and many teams would be as well, but that’s a specific area that Griswold has learned and now has prioritized automated for their whole team. We see this all the time, but the key is these folks, everyone in the room who’s an operator here knows the strategy, they know the tactics, the challenges, how do we implement that at scale without burning people out? Like Kunu said, those mornings, those afternoons, that’s where the burnout happens. That’s where those big picture ideas at the beginning of the year start to fade away and we’re wondering, where’s the turnover coming from? It’s all attributable to the things we know.
Slupecki: Going back to what Victor said initially, what is that preventable piece? What are the pieces that you’re losing out of the bottom of the funnel because you’re not effective on your rewards and recognition program? I think addressing that piece and we have shown a market improvement in turnover since we implemented Ava. We kicked it off last October and we’ve had lots of different metrics along with about a 20 plus percent reduction in turnover. Just for the audience here, when I look at it in terms of what we’re spending on a per hour basis, it’s less than 10 cents an hour. If you think you can have a material impact on your turnover by spending an extra seven, eight cents an hour, I think it’s been a really good investment.
HHCN: Yes, and Victor, I want to hear a little bit more about Ava, your relative newcomer to the home care space. Can you share a little bit about how you came to be and how you entered this space?
Hunt: Sure, of course. High level, Ava is a caregiver and clinician engagement platform. We focus on solving turnover, growth and performance. We do this through a variety of tools from rewards, automated communication, surveys, referrals. All of these are part of the toolbox and it’s all based on the best practices that we know these agencies are applying today either manually or have aspirations to apply and want to do this at scale, all informed in a data-driven way. We’re integrating with the systems at play here, the EMRs for all the scheduling data lives, the training tools where we’re looking to actually increase the skills of those caregivers. We’re putting this on autopilot so that the teams can actually say, “Hey, I want to lower call-outs and I want to run a campaign this quarter to invest in rewarding caregivers who are in fact showing up on time, who are actually doing the right things to encourage other caregivers to show up and picking up those last minute shifts.” This is how we can transform an agency’s culture.
In terms of how I got into this space, this is actually, for me, a very personal note because my family has been in healthcare ever since I was born. My grandmother was a career nurse at Jamaica Hospital. She worked on the emergency room floor. Talk about burnout, that’s the eye of the storm. She decided, “Hey, I want to go and scale the impact I’m having.” She started her own home care business. This was decades ago, back when none of the problems we see headlines about today were even known by half the market, but yet they still existed. There was still turnover, there were still hiring challenges, but it was a very different scenario then. Nonetheless, for her, operating was still a completely different ballgame than being a nurse. She decided, “Hey, this isn’t the right trade for me. Being a business operator, I love helping people, but I want to get back to doing that in a controlled scenario where I’m not having to chase people down to clock in, I’m not having to file all these reports.” My inspiration has always been, what could I have done at that point to create a business that would have made her life easier?
Because we need more operators with that level of expertise coming into the space. We’ve seen the numbers, this space is not slowing down at all, and so we want to give folks that tool set where they can take best operating practices and scale so that running your back office, managing staff is not the blocker to building an incredible agency and provider.
HHCN: Mike and Kunu, I would love for you to share what impacts you’ve seen from working with Ava. Mike, maybe let’s start with you.
Slupecki: Yes, a couple different things. As I touched on, we’ve had improvement in turnover, improvement in retention. We also are an endorsed provider under what used to be Homecare Pulse with Integrated Insights. We’ve always scored super well on caregiver satisfaction, but we’ve actually moved that slightly up. Again, we were already at a pretty high number.
Yes, I think that again, the feedback from our directors has been really positive. It was a turnkey implementation, so not that resistance. I think a lot of us in the room are always trying new things. Sometimes they clearly don’t work. Many times they’re that gray area where you’re trying to justify, did that make sense? This was one of the initiatives that we did. Very easy to see, both anecdotally as well as empirically that it’s had a really positive impact on our business.
Kaushal: I’d follow up and just say the first couple of months when we were doing implementation I had a moment of guilt. We’re actually saving money. This is an odd thing to think about when you think about rewards and recognition because typically for us, I think as organizations, we all say, “Hey, we will open up our wallets in order to get great results.” We rolled in our employee of the month, our incentives for the weekend, referral bonuses, all those programs and dollars, and we said, “Let’s see what this would look like under Ava.” I have to tell you, our scheduling coordinators really fascinated me in gamification at work. You have to struggle and give a caregiver $25 and $50 to take a shift for a last minute on the weekend.
They will do a lot for 1,000 Ava points. That’s like $5 or something like that, whatever it translates to. We were not able to reward and recognize around just real behavior that we really value. We talk about talking in and out. When you’re in a Medicaid space like we are as well, you have to clock in and out. This isn’t a, so it’s easier for payroll. This is a requirement on our end. We are measured at least 90% or higher for clock in and clock out using EVV. We were doing fairly well, but what caregivers really wanted to see was we would call them, message them, and be upset with them when they didn’t clock in and out.
We found that we were not only doing that, we were also contacting them when they did clock in and out correctly, when they referred someone, when they were consistently doing certain behavior, when they refer a caregiver. Candidly, I felt bad enough about it that we had to up all of our point values just because I felt a little like integrity moment there about it. It’s like, we were giving you a lot more to get some of this work done. At the end of the day, we’re saving, let’s call it 20% and being much more effective. We upped our value amount. The caregivers love gamification.
I’ll give you a good example of that is just ask a caregiver how many of them have ever played Candy Crush and they’re on like level 500. They like the idea of being tracked in some way that gets a scoreboard that is bigger than their schedule and their paycheck. They’ve really enjoyed it.
HHCN: Unpacking ROI on rewards and retention programs has historically been challenging for agencies. How are each of your organizations, how are owners building a business case for a program like Ava?
Kaushal: Once again, we have, we’re coming up on 15 years of operations. We have done probably everything in the book as far as tried it all. One of the most ineffective things we were doing was putting major dollars in the hands of schedulers and saying, “Hey, here’s some incentive money. Here’s some money to give to a caregiver of the month.” The distrust came to be. Let’s say it’s $5,000 a month between all of our offices and you give it to someone and you don’t really hear the caregivers get excited about it. The caregivers don’t necessarily have a general pool, you find out and you go back through the numbers, the favorites were getting a lot of attention. One of the biggest ROIs in this is that we know and it’s tracked and it’s audited that we can see everyone is getting that fair treatment.
The brand new caregiver who picks up a shift is getting some incentive. The caregiver that’s been here for three, five, 10 years is also getting recognized. At the end of the day, you would think, well, have we taken some empowerment away from the schedulers? Let me tell you, they’re the happiest people that could ever be. Their phone calls now that come in are asking them, why did I only get 1,000 Ava points and not 5,000 Ava points? Which is a great conversation to have with them versus the game that we were playing before. “Hey, can you take this shift on Saturday? I don’t know, is there a bonus there?” They knew the system and how to work with us. A lot of good behavior.
Slupecki: Yes, I think as we talked, I think we got a really clear ROI with some of the things I talked about earlier. The way we notice it’s working too is you’ll have a caregiver that walks in your office and says, “Hey, I’m really appreciative that you remembered my birthday.” You’re like going, it automatically got the points for their birthday. It was, again, one of those things you didn’t have to think about, it just went out. The other thing too was when we first launched it and we’re trying to figure it out, are we going to see a return, that sort of thing, it occurred to our directors that what they ended up doing initially was rewarding all those caregivers that did a great job just because they were good caregivers. Those are the ones that you forget about sometimes because you spend 80% of your time on the 20% that are just driving you crazy and you’re chasing around. Then those ones that perform bad, they actually do something good and you give them money. You don’t give money to the ones that are doing good stuff every single day. It actually felt better to our teams to know that they were rewarding the ones that just did their job, where before those were the ones that were being neglected. I think that also goes to that retention piece as well.
HHCN: What are some other trends that home care operators should be paying attention to in the next one or two years?
Hunt: A major thing that we’re hearing all the time is the 80-20 rule. It’s no surprise that teams are needing to get more efficient about how they’re spending money, be it on salary or be it on tools. Our focus has always been on scaling the personnel that exist and scaling those best practices. For us, it’s really understanding how we make those schedulers’ lives feel so much easier by putting these tools in place where they feel like they can have that reach. Folks like Kunu and Mike don’t actually have to hire an army of back office folks to actually call and check in, “Hey, did you clock in?” “Hey, happy birthday.” That stuff is happening now at scale and it’s continuing to improve. The motivation there, of course, is that we’re not getting much higher reimbursement rates. We’re not getting the level of change that we need to compensate for this looming change of 80-20. We have to get a lot more efficient and a lot smarter about retaining and especially about scaling our back office.
Kaushal: I’ll piggyback on that. I didn’t see some of you this morning because I was literally at a Medicaid director’s office speaking about 80-20, because welcome to Tennessee, by the way. In our conversation, one of the things that’s going to happen around 80-20, just to keep piggybacking on that, they are limited on their funding. What they are telling us is essentially don’t bank on the idea that reimbursement is just going to go up. The reason that we’ve got a six year heads up around some of this stuff is for us to be working on these types of programs.
I would just say for those that do private pay and you think 80-20 doesn’t quite apply to you or something to that extent, just realize that means Medicaid, which has already seen some reimbursement hikes over the last COVID era, post COVID era. Those rates are there. Some of those organizations are also going to start paying more to the caregiver. In some states where Medicaid rates are getting pretty close to private pay, the wage of caregivers is going to start going up. Just in Medicaid, it’s not an affordability issue. We work off of authorizations. If we’ve got the work, the clients are typically with us. Our average length of stay on Medicaid is four and five years. Just a length to say on a client that’s getting 30, 40 hours a week, it’s good work, and now reimbursement comes up. We are going to see a competitive nature. We’ve already seen that with VA. I think there’s probably people in the room that have seen reimbursements go up, so you’ve been targeting VA. Billing with VA has become easier, so now you’re moving towards that. I think in some way, however 80-20 works out, that will become a strategy and a trend that you will find the Medicaid programs are actually a really good business for the caregiver from a wage side.
Slupecki: I think just like the speaker this morning said, use AI wherever you can use it and use things to drive efficiency. This is just one of many ways we have to keep that personal touch. I think it’s cliche. Our business is a personal touch business, but anything we can automate, anything we can throw AI at, that doesn’t impact the relationship we have with our clients and caregivers, do it.
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