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Episode 23

The financial outlook of Home Care in New York State with Personal Touch Home Care

Jeff Howell (00:01):

Welcome to home health, 360 a podcast presented by AlayaCare. I’m your host, Jeff Howell. And this is the show about learning from the best in home healthcare from around the globe.

Jeff Howell (00:18):

Hey everyone. And welcome to another edition of home health, 360, where we speak with home care and home health leaders from across the globe. Today, we have Denise Tripodi, who is the vice president of the shared service of personal touch home care in New York. She has a strong program and project management background in home care, elder care, healthcare, healthcare management, and long term care, and has been at personal touch in New York for 20 years. Denise, thank you for being on the show today.

Denise Tripodi (00:51):

Oh, thanks for having me, Jeff. Thank you so much.

Jeff Howell (00:53):

So Denise, we haven’t had a chance to speak before, but I just randomly reached out to you about your LinkedIn post when you guys acquired Bronx’s community home care, also known as neighbors home care. And so that transaction was completed early April. And so now I think personal touch has according to the press release about 4,500 caregivers and about 3,600 clients in New York city, long island and Westchester and the move places you folks among the largest license service agencies or what we call LS. And I think that’s only a New York term. I haven’t seen it in any other.

Denise Tripodi (01:34):

It is Jeff. It is got it. We like to be different yep. Yep.

Jeff Howell (01:37):

Well, tell us a little bit more about personal touch and your time at the company

Denise Tripodi (01:42):

I’ve been with personal touch for 22 years. I like to tell the joke I started when I was five, but like that’s an old joke, so I won’t even say it. Personal touch has been in business since 1974. It was originally owned by the GLA back and Mark’s family. That’s how it was started. Dr. GLA back will tell the story of the first weekend they were in business. We had three patients two passed away the very first weekend. So his story is, look, we lost two thirds of our business. The first weekend we were in business and here we are, we’re still here so that we persevere a as we stand now, the company is still owned. A third is owned by the cloud back family. A third is owned by the marks family and a third is owned by us, the employees.

Denise Tripodi (02:30):

So we have an ESOP, which is an employee stock option plan. So that’s great. The company began in New York with the offices that I own with the li of the license services. And through that, we’ve kind of grown. We, we grew and then consolidated a little bit. We were in New Hampshire, Massachusetts, New Jersey, Ohio, Kentucky, Virginia, West Virginia. We also had a very small early intervention program in New York. We divested of early intervention last year and we’ve closed some of the offices. So today we exist in, in New York and in Virginia, West Virginia, Kentucky, and Ohio we have two, two types of business. We have my business, which is the Alexa or people call it unskilled. I hate that term unskilled. So we’ll just call it personal care services. And then we have skilled services, which is really nursing nursing care.

Denise Tripodi (03:31):

So that office exists also in New York as well. Mm-Hmm part of our history, part of our fabric is in 2015, the company applied for and received approval from the state to start Medicaid managed long term care company. So we were the parent organization to Integra, which was a Medicaid managed long term care Integra grew in seven years to become the second largest MLTC in New York state mm-hmm . And we’re happy to report that Anthem health just acquired that insurance company from us earlier this year about a month or so ago. So that’s where we are with personal touch. The other line of business that we have in New York is our CDPAP, which is our consumer directed assistance program.

Jeff Howell (04:18):

And CDPP is probably the largest self-directed care program in all the United States, right?

Denise Tripodi (04:25):

Yes, indeed. It is.

Jeff Howell (04:26):

Yes. And I, and I think it goes by different names in different states, but some states you don’t hear anything about it at all. And, but in New York you hear CDPAP all the time.

Denise Tripodi (04:34):

Yeah. I think a lot of it is based on, on need and just the demographics of where you are. I mean, I remember when CDPAP was in its infancy early in the nineties and it was really geared, geared towards a group of individuals that had caregivers and they kind of wanted their freedom. They wanted to be able to say who cared for them. And not only that, what the services were that were provided to them. So I think now the mindset is, is well CDPAP it’s, family members, caring for family members. It’s so much more than that. The caregivers are able to operate outside of what we call a scope of practice. So say for example, if you’re a young person, a young person in their thirties, maybe disabled, you want your caregiver maybe to go with you to Walmart, or you maybe want your care caregiver to go with you to, to the local bar, right.

Denise Tripodi (05:27):

Just because you can’t get around that would not be within the scope of practice of a, of a personal care aid would be to go, go to Walmart with you or go to the local bar, but in the CDPAP program, they are permitted to do that on the flip side, and they’re also able to do things like inject insulin, if the consumer actually directs that personal assistant to do so. So that’s a little bit quick down and dirty difference between CDPAP and what live run, and which is the personal care services.

Jeff Howell (05:59):

Sure. So how many, how big would your CDPAP program be?

Denise Tripodi (06:03):

We have about 725 recipients. And probably I’m gonna say somewhere in the vicinity of maybe 12 to 1400 personal assistance.

Jeff Howell (06:16):

That seems like a big program.

Denise Tripodi (06:18):

Yeah, it’s, it’s fairly large. We’ve only been around since 2016. So we grew pretty quickly. We saw a lot of girls in the CDPAP arena around that time with the Medicaid redesign team. So it’s not unusual that the CD pipelines of business crew exponentially during that time.

Jeff Howell (06:38):

Okay. Yeah. I had never put that into context before. So speaking of which there’s still a moratorium on Medicaid agencies at New York, and to my knowledge, it’s just New York and Florida that actually have moratoriums. Can you provide us a bit more background? When did this come into place originally?

Denise Tripodi (06:57):

So the state’s gone two rounds with it, right. In order to understand where we are now, you have to know where we’ve been. So let me take you back a little bit. The, the moratorium was lifted in 2010, prior to 2010. It’s much the way everything is existing. Now there was a shortage of caregivers in the late nineties. We didn’t have enough care to be caregivers around. The wages were not really formalized. They were not standardized. So the state said, well, we’re gonna lift this moratorium and we’re gonna get more Lexus. That, that was the state’s solution to the problem. Prior to the moratorium, there were only 920 licenses that were out there once the moratorium was lifted. By 2012, it had increased the 1400 today. We have almost 1500 licenses in New York state. So now the state says, well, oh my goodness.

Denise Tripodi (07:54):

Yeah, that helped during that time period. But now we have too many licks, a lot of competition. A lot of caregivers it’s the same labor pool. That’s just kind of being spread across 14, 1500 Lexuses. And that was not what the, the state had intended. They wanted to get more caregivers into the industry. I don’t think they were really very successful in doing that. A lot of that also transpired around the time of 2011 with the Medicaid redesign team fee for service, Medicaid was eliminated. And it allowed prior to the Medicaid redesign team, the li really couldn’t survive in New York, unless you had a contract with your local department of social services or what we called HRA human resources association. Once the Medicaid redesign team came out, they eliminated HRA. They eliminated fee for service Medicaid and said, okay, Lexus.

Denise Tripodi (08:49):

Now you have to deal with insurance companies like in Integra, like Aetna, like health first that we had never, ever had to deal with. So there was a scramble. Everyone said, Hey, this is great. I can now get a license. I don’t need to have my HRA contract, my fee for service Medicaid contract. I can go out there and just contract with Integra and I’ll survive. It’ll be a lucrative business. So that’s where we saw such an influx and more applications of, of licenses come around was right around that same time with the Medicaid redesign team. I know that’s a whole lot of information, a lot of complex complexities to that, but I think that answers your question. Yeah.

Jeff Howell (09:30):

So I only picked up the first time you said it was two rounds and it was lifted in 2010.

Denise Tripodi (09:36):

Right. And then they put, and then they put it in place again in 2020. That’s why there was two rounds, right? So there was a moratorium, they lifted it in 2010. They had it for 10 years. It was, it was the wild west. And now they’ve put it back again.

Jeff Howell (09:49):

Got it. Okay.

Denise Tripodi (09:51):

My opinion is that the state wants consolidation. They’re forcing consolidation in the market. They’re limiting the amount of, of, of licenses. They’re also pushing for the li RFO right now. They’re looking for consolidation. I think the state, what they want is they want consolidation with Medicaid, managed long term care companies and Lexuses, that’s clear, it’s abundantly clear. That’s what they want. So they’re gonna drive that consolidation in the market.

Jeff Howell (10:20):

Makes sense. And to your point, you know, it’s like when you go get three bids on your roof, right? From three, from three roofing companies, they’re probably gonna use the same trades to do the actual shingle work. Right. right. And so you know, the goal would really be, have a fewer number of really well run agencies that can compete and survive. And, you know, it’s, it’s a delicate balance of not having enough and then having too many, and that doesn’t work either,

Denise Tripodi (10:49):

Right? And they want the state wants compliant, licensed home care agencies, folks that are gonna follow the rules, being compliance with wage parity, being compliance with a number of different things. And so I think that again is what the state’s goal is. And also obviously to save money, right? They, they wanted, the reason for the creation of the Medicaid redesign team was there was an exorbitant amount of money being spent in Medicaid dollars. In home care about 58% of the money was being spent actually in Brooklyn and one particular borough. And the state said at that time governor Cuomo was the attorney general. And he said, look, there’s something going on. There’s something not right here. So we wanted to come, come back, reevaluate, make sure there wasn’t any fraud and abuse. That’s why we came up with the Medicaid redesign and Medicaid matters, long-term care companies. And I think now that what we’re still seeing is the tailwinds of that. That was the goal then, but I don’t know that the state was as successful as they had wanted to be. So again, that’s why I think they’re forcing this consolidation. They’re gonna get rid of these smaller agencies, maybe agencies that are not as compliant. They’re maybe I hate to even say it might be involved in fraud abuse, those kinds of things. I think that’s the goal of, of the state is to eliminate that.

Jeff Howell (12:09):

Yeah. Sure. So with your acquisition of Bronx community home care did the moratorium play a role in, in you know, speed bump in your way to acquiring? Or how does that work?

Denise Tripodi (12:21):

It did not because we did exactly what the state wanted us to do. So Bronx community held the license to operate in the five boroughs in Westchester, personal touch has licenses to operate in that same space. So they will close that license out. So there’s one less license after we acquired neighbors. So we helped

Jeff Howell (12:43):

You’re doing, you’re doing your part that’s

Denise Tripodi (12:45):

Right. That’s exactly right.

Jeff Howell (12:47):

And yeah, I, I presume you guys are still in expansion mode and you’re looking at any other strategic acquisitions like growth by acquisition. I would imagine is a strong way for you to keep things rolling in New York.

Denise Tripodi (13:01):

In fact, it is especially again in this market, right. It’s been tough. It’s been very tough for us to grow organically because there’s so many, a lot of competition, not only with all those ES, but the CDAP programs we talked about earlier, there’s been a lot of competition with us, not only within our business, but also within other industries. You know, when they level set the, the minimum wage in New York to be $15 an hour, they level set that wage with home Depot and Walmart and food service industry and anywhere else. So now, in addition to personal touch competing with 1500 licks, we were competing with 900. Now we’re competing with 1500, we’re also competing with other industries. And so that’s not just personal touch, that’s the industry. And so they kind of sucked a little bit of our caregiver, our labor pool. So it’s been difficult for us to grow. So again, I think that acquisition is certainly one of our strategies for growth. We’ve established a really good efficient model where we can do business in a much more efficient way through technology. And that is that I think that’s where it’s at. I don’t think we’re the only ones that are doing that either.

Jeff Howell (14:18):

So speaking of the the minimum wage you know, there was just that increase, but not a corresponding bump to the reimbursements as well.

Denise Tripodi (14:30):

Right. So we are thrilled that the caregivers are getting more money. That’s I think that’s an amazing thing. The work that the care caregivers do they’re they are undervalued. I think home care workers just as a whole are undervalued, but that’s just me. So for them to get, they’ll get an extra $2 an hour starting October 1st of this year, and then another dollar an hour starting October of 2023. So we’re thrilled about that. However, the agencies we there’s been little to no discussion about the reimbursement rate. I believe that the state will come through with some money. If again, I take you back to the late nineties when we had a caregiver shortage the state put into place what was called recruitment and retention money. So added onto our FIFA service Medicaid rate the state gave us, I think it was like three or $4 more an hour, and that money had to go directly to the caregivers. So we couldn’t use it as profit, no bonuses, nothing like that. We had to clearly show the state, this went directly to the caregivers. So I’m thinking, I’m hoping that that’s something that the state is gonna come back with and that money will be funneled through the contracts with the Medicaid managed long term care companies. I just don’t think they know yet.

Jeff Howell (15:46):

Right? Yeah. I mean, there’s Medicaid is more of a volume play, not a margin play. So if there’s a mandatory you know, improvement, which is great for the caregivers, there’s there’s not a lot of meat on the bone to squeeze out you know, the money has to be there. Right. So, right.

Denise Tripodi (16:04):

It’s like you’ve done this before Jeff. That’s exactly right. It’s always been a game of volume. It’s a, it’s a penny margin business and always been a game of volume.

Jeff Howell (16:12):

Yeah, for sure. Well, speaking of money, it actually just occurred to me in real time here. If a company can use FMAP funding for acquisitions, I’m wondering a cuz I’ve read some FMAP documents and it talks about, you know paying, you know, people more and investing into technology and so forth. But I’ve actually, I don’t, I think it might be silent on whether you can actually do that to go help fund a new acquisition. Do you know the answer to that?

Denise Tripodi (16:39):

I don’t believe it can. The money is, is really earmarked towards recruitment, retention, technology education and value based payment programs that, that is clear what, what the state wanted us to do with it.

Jeff Howell (16:56):

Yeah. Do you what are you seeing out there in terms of how agencies are applying these dollars?

Denise Tripodi (17:02):

I think you’re gonna see a, a garden variety. I think there are those agencies that are organized, we’re organized. We are, we are union represented by 1199 S E I U. So the union of course is gonna advocate for the caregivers and really the bulk of that money. And my opinion should be spent on recruitment and retention. We we’re experiencing a shortage. That’s where we need to put that money. There is a huge bulk of FMA money that’s supposed to come in a second wave. I believe that’s going to be the funding for that two to $3 an hour rate increase. We’re gonna see that happen. That’s where I think that money’s gonna be

Jeff Howell (17:41):

Funneled. Oh, I see. You’ve heard it here first folks.

Denise Tripodi (17:45):

, let’s hope it sticks.

Jeff Howell (17:48):

Yeah. Yeah. Maybe you’re gonna help influence the, the trend

Denise Tripodi (17:53):

right. Right.

Jeff Howell (17:54):

So you’ve talked a lot about how, you know, Medicaid has evolved and changed over the years. This is the first time I’ve ever heard of 58% of the money being spent in one borough. That sounds unbelievable. Not only that it happened, but that, you know, we were able to sort of track that down and say, Hey, we need some reform here to, to try to address these things, any predictions on you know, I know that so most people I speak to, they all say that their state has the most complicated Medicaid system, but I think New York actually genuinely takes the cake on that. Just curious if you have any predictions on how things may change moving forward with Medicaid in New York.

Denise Tripodi (18:38):

I think that Medicaid in New York, we do have to save money. I think that we’ve, I think what we’ve done is we’ve kind of swung the pendulum the other way. We went to a very liberal from a very liberal environment where everything was for us, it was volume. It was long hours. Patients were getting what we refer to in the industry as two by twelves, right. So it’s round the clock care. And, and I don’t believe that was appropriate, right. Because if you were to receive round the clock care two by 12, maybe there’s another option for you. I think what happened now. COVID okay. We can talk a little bit about that, where we have folks that are working from home that are staying home. So I think you’re gonna see some people actually maybe care for their, their parents or their family members and not take Medicaid dollars.

Denise Tripodi (19:35):

That’s one thing I think you might see. And then the pendulum has to swing the other way in a way that, well, the MLT CS want very, very low utilization. So we went from two by 12 to seven by two, somewhere in the middle is the sweet spot. These patients, you know, if you look at industries throughout, you know, from the 1960s or, or prior to that, to now, it’s always been about the baby baby boomers, right? When the baby boomers were children in the toy industry boomed when the baby boomers turned 16, 17 years old, the car industry boomed, right? So now you’re seeing another boom with healthcare home care. These people want to stay home. That’s where they’re safe. So Medicaid, I think, has to come back and say, really, take a look at this and say, Hey, what’s the best way, the most efficient way for, for patients to stay home.

Denise Tripodi (20:27):

I think you’re gonna see some technology come into play. I think you’re gonna see risk share, come into play with value based. I think value based is a huge component right now. What we will see come about with our Medicaid, we see that already happening on the federal level with Medicare. So I think Medicaid typically what happens in our industry, you see it happen first with Medicare and then it’ll trickle down to Medicaid. New York usually gets hold of it and complicates it a little bit. But somewhere in there it’ll, it’ll come out as a, as a value base. So that’s where I see us moving.

Jeff Howell (21:01):

Yeah. Well, it’s almost like you can see what my questions are here because that was where I was going next. is that you, so you guys have a cha as well, right? I’m assuming you guys are like half looks a half cha and for the, for the listeners, cha is the New York specific acronym for certified Medicare agency. And the rough number that I hear is about a third of agencies actually don’t really even track any outcomes today. And so I was curious your thoughts on you know, you said that I love how you said, you know, it, it typically the, the litmus test is the Medicare space and then, and then it moves into the Medicaid space. Are you guys doing any tracking of outcomes and predictive analytics? And I’m curious if you’re also looking into technology to predict caregiver turnover and shortages and, and whatnot.

Denise Tripodi (21:57):

So the industry as a standard, I think is sort of lacking in any kind of ability to track outcomes. I think that we look at the state and say, Hey, New York, what do you wanna track? And New York looks to us and says, well, what do you want to track? So I think there’s a, there’s a conflict there. I think first thing that we should track as we should take a look at falls and how we can avoid falls, that’s, that’s one piece. And I think we have the ability to utilize technology. I think one of the biggest things that we need to look at is the social aspect of home care. I think in general, we lose that piece, right? I think what’s important to people and our outcomes is even maybe a patient’s mental and emotional wellbeing, right? So why can’t caregivers like a hybrid between CD P P and, and Alexa, why can’t caregivers go out to a patient’s home and assist a patient?

Denise Tripodi (22:59):

And I don’t know, maybe cooking a meal or maybe gardening or, or listening to music together, or, or a podcast with Jeff Howell. Why can’t they do that? Mm-Hmm, , you know, Medicaid, doesn’t pay for that, but I think that’s enrichment in the patient’s life. And I think that’s gonna keep a patient home safe and keep their faculty. So they’re not gonna fall. They’re not gonna injure themselves. So I think we have to take a look at the patients more holistically. That’s one thing. And I think from a value based perspective, there has to be a risk share, right? Because you always have those outliers. You have those patients that are on what I’ll call the low end, that they can kind of stay home and be more self directing. Maybe they don’t need a lot of services. And then you have the patient that really does need two by twelves live in services.

Denise Tripodi (23:46):

So the MLTC have to get the agencies to do some risk share and yes, on a child level, on a Medicare level, we are tracking outcomes. I think agencies have the ability to do that. It’s easier, I think, in the Medicare world to track those outcomes because it’s so clinically driven, the child world is so clinically driven. We’re not the second part of your question was technology to track caregiver turnover. Yes. I think you’re definitely going to see that we’re already doing that. We’re starting to understand the needs of the caregiver right now. We will be engaging the remainder of the year with our caregivers to do a full fledged survey with them, some focus groups we wanna understand. Why did you become a caregiver? Why did you choose personal touch? Why are you still here? Why haven’t you gone somewhere else? So those kinds of questions, I think we also need to understand from a customer service perspective and, and how to properly engage with our caregivers, they are our product without them. We don’t have a job. So we have to create an environment where we’re able to give back to them. Other than that, you’re gonna be left with Medicaid recipients, providing care for Medicaid recipients. Right. And that’s, it’s not gonna work.

Jeff Howell (25:07):

Yep. Yep. Going back to what you said about the social determinants of health, right. So Medicare advantage was really the big signal that Hey, maybe upstream. The very first thing we should worry to be worried about is this Maslow’s hierarchy of needs that, you know, after you have food and shelter, you seek to have companionship and community and self-esteem, and it, and if, when you have those things, your health will be in much better shape.

Denise Tripodi (25:40):

Absolutely. And didn’t, didn’t, COVID teach us that among a million other things, right? Yeah. Yeah. That, that people that when they were isolated you know, I have parents, they’re 84 years old. They lived very close to us before COVID, my dad was working, he’s now he’s retired, but I can definitely see a change in, in, in them and in how they engage with us. It, loneliness is a, is a huge, a huge, huge player. You know, it’s not an easy thing for you to think about aging. And what does, you know, really what comes after aging right? Is, is hospitalization is death, is, is nursing home. So it’s scary. And I think that we have to, as, as caregivers and as providers, right, we have to think about that patient. Isn’t just skin and bones. There’s a lot of other factors that are going into that.

Jeff Howell (26:31):

Well, this pandemic has tr taught me to be a lot more grateful as well with you know, the way that it’s in influenced everyone’s life. You know, so tremendously over the last two years, I will we’re almost bumping up against time, but I’ll get you outta here on this last question. Denise, give us a reason to be optimistic about care in the place where clients call home.

Denise Tripodi (26:55):

So here’s what I’ll tell you home. Care’s been here for years and years and years. It’s been here since the turn of the century, right? VNS and Y also metropolitan Jewish. There are pioneers we’re here. We’re not going anywhere. People are always gonna be home. We know COVID taught us that too home is the safest place to be. So I think this bump in, in rate increase to our caregivers much needed is very, very optimistic for us. Hopefully we’ll be able to get an infusion of, of new caregivers that are coming in. That’ll be able to carry on our strong tradition of quality caregiving.

Jeff Howell (27:34):

Well, it’s been amazing. I wrote down so many notes here of the new things that I learned and I will steal home is the safest place to be. I might refer, I might give you credit for the first time or two, but then I’ll, I’ll keep it as my, if you use

Denise Tripodi (27:47):

It three times, Jeff, it’s yours. That’s how it goes.

Jeff Howell (27:50):

well, it was great to have you Denise really enjoyed this session and hope to have you on again some other time in the future.

Denise Tripodi (27:59):

Sure. Thanks so much.

Jeff Howell (28:02):

Home health 360 is presented by AlayaCare. First off, I wanna thank our amazing guests and listeners to get more episodes. You can go to that’s spelled home health 360, or search home health 360 on any of your favorite podcasting platforms. The easiest way to stay up to date on our new shows is to subscribe on apple podcasts, Spotify, or wherever you get your podcasts. We also have a newsletter you can sign up for on to get alerts for new shows and more valuable content from AlayaCare right into your inbox. Thanks for listening. And we’ll see you next time.

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Episode Description

Some states have an advanced self directed attendant care program where neighbors for relatives who are already acting as caregivers can be an extended workforce for home care agencies. New York State’s program is called CDPAP (Consumer Directed Personal Attendant Care Program). On this episode, we welcome Denise Tripodi Vice President of the NY LHCSA Shared Services at Personal Touch Home Care, who sheds some light onto NY’s CDPAP program and how it works within her organization. We also dive into topics related to FMAP funding, and Personal Touch Home Care’s recent acquisition of Bronx Community Home Care.

Episode Resources