How Resilient Healthcare Cracked the High-Acuity Care at Home Code

Unlike some of the newer higher-acuity care in the home models that have launched in recent years, Resilient Healthcare was formed out of personal experience – not from pandemic-related challenges.

In part, that’s why Resilient CEO Jackleen Samuel and her team were ready for the overarching shift that is now underway. Among its services, the organization provides hospital-at-home, SNF-at-home and traditional home health care.

But as more patients have been able to be treated in the home, the company’s mission has been validated.

Samuel started the company in 2018, at the age of 26, with support from the private equity firm Mezas Capital. Since then, the Texas-based company has grown steadily, thanks to both internal success and the external tailwinds at its back.

And though the Centers for Medicare & Medicaid Services’ (CMS) “Acute Hospital Care at Home” waiver has been good for business, Resilient already knows how to live without it.

HHCN is pleased to share the recording and transcript of our HHCN+ TALKS conversation with Samuel. Read on to learn more about:

– How the company got started earlier than most on providing acute care in the home

– The potential challenges for the hospital-at-home model in the future and the looming competition from other home health providers in the SNF-at-home arena

– Why Samuel loves value-based care contracts and how her company makes them work

– Where the “Acute Hospital at Home” waiver could be improved

The below is edited for length and clarity.

[00:00:06] Andrew Donlan: Welcome everyone to another edition of HHCN+ Talks. I am Home Health Care News editor Andrew Donlan. We have another exciting edition here with Jackleen Samuel, the CEO of Resilient Healthcare. First, let’s get into your background and Resilient’s background, Jackleen.

[00:00:28] Jackleen Samuel: Thanks, Andrew. I’m a physical therapist by trade, and Resilient started pre-pandemic. I was working at a home health agency, and my father had had a stroke, and another stroke, and another stroke. He was in and out of hospitals for the last four years of his life, and too high acuity for traditional home health, but not technically eligible for hospice.

He fell within that chronic care management patient category, and he was getting transported all over the place. And so Resilient came about by trying to fix that gap in care. I worked with some of the hospital execs and hospital CMOs and said, “Why are patients coming back? What can we reproduce in the home?” Then I worked with lawyers and tried to figure out what is within our scope of practice, and we launched Resilient at the end of 2018.

[00:01:28] Donlan: Launching a company at the end of 2018 is interesting, just given the timeline of what has transpired over the last couple of years. How have things changed internally? Because, obviously, you had a year under your belt before COVID, and then during COVID, your vision was somewhat validated. Doesn’t it feel like that?

[00:01:48] Samuel: Oh, absolutely. We shifted a few times. When we first started, it was a lot of research and development – even explaining what we were doing and how it was different from traditional home health. That has shifted. Now, people just know, “Oh, OK. You’re doing that hospital-at-home program.” But for that first year, it was a lot of, “Well, this is why we’re doing it, and this is the difference,” and all of that.

Then, when COVID happened, we shifted pretty quick. We were one of the first companies in Texas to do PCR testing in the home. We started at the end of February. We did a lot of pre-op testing for hospitals as well and managed COVID patients in the home.

Internally, we shifted during COVID. When testing became a little bit more prevalent and easier to get, we shifted back to really taking care of those high-acuity patients at home.

When Medicare announced the hospital-at-home program, we knew we were well-suited for it. This is what we’d been doing. Our vision, our company, everything we set out to do has been validated through the pandemic.

[00:03:09] Donlan: Just to take a step back, can you let our audience know all the service lines that you guys provide? Because I know you do a little bit of traditional home health as well.

[00:03:18] Samuel: Yes, we do have a traditional home health agency. That came after the fact. We have our high-acuity care model in the home. We call it “long-term acute care at home,” rather than long-term acute care hospital or SNF-at-home. Whatever you want to call it, really, it’s interchangeable. That is physician-driven interdisciplinary care, and we contract with insurance companies directly and other payers.

Then we have our hospital-at-home program, where we partner with hospitals, and we stand up the acute care program for the hospitals, we stand up transitional care for the hospitals, and we stand up a lot of outpatient community-driven care. Within that, yes, we have a home health agency. It only operates in North Texas. We end up working with a lot of the local home health agencies as well. Then, we have our technology. We have a few different verticals and different service lines.

[00:04:24] Donlan: When we chatted with you earlier on last year, you were explaining that, basically, before all this, you’d have to prove your worth to payers or insurers, and then the money would come later. Has that changed?

[00:04:47] Samuel: Well, that’s health care. Typically, in health care, you do the work and then you hope to get paid, and you hope to get paid what you think you’re going to get paid. I think that is just the industry.

At first, we were doing something so outside the box that you’re explaining to payers what you’re doing and why you’re doing it. … That was our beginning. It’s a little different now. Now when we talk to payers, it’s more mentioning, “Hey, this is the population health approach. We have stood up this model where we can deliver hybrid care for the sicker patients.” We now approach it differently, but I think payers also understand the space a lot more. It is definitely easier to get through those conversations.

[00:05:40] Donlan: You said you do have that home health agency, but also your work with home health agencies in some capacity. Where is the marriage there? Why is that important to be able to work with those providers?

[00:06:08] Samuel: A few reasons, I would say. We could go in there and say that we’re going to stuff it all ourselves, and we’re going to stand it up ourselves, but it’s really not appropriate in some areas, especially if there is a home health agency that is established in that community. They may have seen these patients before and so we like to see ourselves as that layer in between.

We set up the hospital with the technology and the operations and the management, and we help them with contracting. At that point, why recreate the wheel? There are nurses and providers that are embedded in those communities. Why don’t we just train them up to more of an acute program in patients’ homes and work with them instead of against them? That’s always been our model and we’re going to stick with that model.

[00:07:01] Donlan: You guys have always honed in on those complex patients. Sometimes, historically, that hasn’t always bore a lot of fruit for providers from a bottom-line perspective, because it’s harder to take care of those patients. Are you excited about the prospects of value-based care in that it’ll more recognize the effort that you guys are putting in? Is that something that you see as a tailwind for you all?

[00:07:29] Samuel: I think what you just said is the reason we had that gap in health care to begin with. You have these chronic care patients and they do need more care, but you send them back to the hospital because nobody really wants to touch those kinds of high-service areas.

I love value-based contracts.

We really have a good hybrid type of model where we have good outcomes. We’ll put our money where our mouth is, in the sense that we say, “Give us these patients. We’ll show you that providing them more care and more convenient care in their homes will actually reduce their overall cost of care.” That’s a conversation we’re very comfortable having, and that’s a contract we’re very comfortable taking on, even if it is a high-risk contract.

[00:08:23] Donlan: You also see CMS recognizing this with the ACO REACH model and other models that are recognizing the fact that equity needs to come first. My next question is, like I said numerous times already, you guys were early on a lot of these models, but what have you learned over the last few years and what have you tweaked clinically, if anything?

[00:08:54] Samuel: When we first set out to do this, we were like, “Oh, we’re first in doing this. We really want to change this. This is going to be great.” The pandemic happened, and we saw a lot of shifts in the industry – that more companies are going to want to start doing this. But we had already developed technology and worked through a lot of different workflows and situations on how we reduce our risk and how we improve safety and all of that.

I think one of the lessons learned is don’t recreate the wheel where you don’t need to. Another is that you’re going to have to continue to innovate every single year, or even every quarter, because the industry is changing. Also, we have a lot more technology now. When we started, we didn’t have our tech arm. We started on the service line only. A lot of care coordination was done on various different systems. That’s why we created the technology.

As we continue to progress, we’ll continue developing that technology. A lot of the thinking behind that was: We have access to social media and we have access to Amazon Prime, and I can get something delivered in two hours, but people can’t contact their physicians that easily or physicians can’t tap into how their patients doing that easily, especially if they’re not in the hospital. And we built up that technology to really clean up care coordination and reduce miscommunications in health care. And then also, to give patients access to providers and to give providers access to their patients.

[00:10:40] Donlan: What have you learned about these types of patients in this process?

[00:10:54] Samuel: It’s actually incredible to see how patients are different in their home environment, especially at that acute, in-patient level. Patients want to do this. They’d rather be treated at home if they can be. But things we didn’t think of is how, for instance, this patient says that they are so excited about this program because they didn’t want to be away from their cat for too long. Or, we’re fixing a problem of patients discharging themselves from the hospital against medical advice, because they want to check on their dog because their neighbor couldn’t. There’s little things like that, and it’s just incredible to hear.

It’s a different relationship with the patients at that point. It’s a little more intimate. You’re talking to their families. You’re there in their home, you’re in their space, you’re respecting their space, and I think they actually do recover a lot faster that way.

[00:12:00] Donlan: The CMS waiver obviously changed everything. Is there anything in the program that you think CMS got wrong about the model, about what are best practices for hospital at home?

[00:12:22] Samuel: I think the biggest thing is, right now, with the CMS waiver, the patient has to be identified at a hospital and has to have come from the hospital. And I understand why they did it like that. I do think that as this program progresses – and hopefully, the waiver gets extended for two years as they just introduced it – I hope that they allow those physical exams to be done in the patient’s home, rather than after they went to the hospital. I think that we can knock out that transport as well.

We’re working with EMS companies, or we’re working with paramedics. We’re working with everybody involved in that community. We can identify if a patient is going to be admitted, and you can still use the same criteria to admit a patient right in their home, from their home, without transferring them to the hospital first. Now, of course, if the patient needs to go to the ER, and they’re having an emergency situation, that’s completely different.

I think that would be the only thing that I would hope gets changed in the waiver at some point. And as all of these hospitals start launching this line of service, there will be more data that we can learn from. Hopefully one day, CMS might eventually be comfortable saying, “Okay, you can admit these patients right in their home, from their home.”

[00:14:01] Donlan: In terms of the legislation that you just mentioned, how optimistic are you about that extension to the waiver? Is that something you believe has the chance to become permanent?

[00:14:27] Samuel: We’re hoping so. We signed the request, and we know a lot of other companies that did. It’s the right next step. It is more convenient care for patients. It is technology-driven, it is safe, it is more effective, and it’s less cost. Now, eventually, I don’t think that they’ll be paying for a full in-patient stay while the patients are in the home. Because how else would Medicare save money, then? That being said, yes, I’m pretty optimistic. There’s been a lot of push in health care to become more innovative, and so this would be the right next step, and I think the government’s been pushing that way too.

[00:15:16] Donlan: What do you think about the part of the legislation that would require CMS to come up with basic measures for the waiver program and providers within it? Do you think certain measures are needed for every provider delivering this type of care?

[00:15:34] Samuel: I’m going to have to go with “no,” just because every hospital operates differently in every community. If you’re working with a rural hospital versus an urban hospital, and if you’re working with a rural community hospital compared to a big publicly traded hospital in a city, then there are going to be little nuances that are not going to match.

If you try to force these smaller, rural community hospitals that are already struggling to match that agenda, then it’s going to be more difficult and costly for them to launch this, even though they might be able to do it safely their own way. Of course, there are conditions to participation and outcome expectations. I think those are both fair, but in terms of workflows, I think there needs to be a lot of variance.

[00:16:24] Donlan: Then, in terms of the waiver itself. What does that do for you guys just from a validation perspective as well with other non-Medicare payers? Just from the perspective that, “Hey, Medicare is doing this as well.” Does that help?

[00:16:58] Samuel: Yes. The waiver is for Medicare. Of course, I hope that it stays, especially because that population is the most at risk for hospitalization. If it gets extended, that validates the model for a lot of payers as well. But I think that payers are open to just listening to outcomes and how patients are getting more for less and all of that. Remember, we started before there was a waiver program. If the waiver goes away, we’ll continue, but Medicare would be excluded and that would suck.

[00:17:39] Donlan: How much of a tailwind, from a bottom-line perspective, has it been for you guys to have that Medicare revenue stream?

[00:17:51] Samuel: Oh, it’s been good. We partner with hospitals a little differently. We help set them up with the program. We provide technology for the program. We integrate it with their EMR. We do a lot of heavy lifting on the front end, and then going forward, we’re still helping the hospital operate, and we provide care for the patients in their homes. It’s been good, but the hospital is our payer in that sense because we’re essentially a technology service company.

I think that’s another thing too with the waiver: There are no technology requirements right now. I think at some point, there will have to be some tech requirement if you’re providing this level of care for patients in their homes.

[00:18:48] Donlan: Then moving off hospital at home, you guys obviously have that SNF-at-home component. Has it been interesting to see some of the larger home health companies get into that space? That’s another area where you guys were ahead of the curve.

[00:19:09] Samuel: It’s been very interesting, especially the really big home health agencies. They make a big splash when they say they’re getting into acute care at home. Initially, you’re like, “Oh, lots more competition,” but we spent so much time ironing out workflows and getting experience in the space, and then developing technology to be able to provide this level of care in the community. So I’m okay with it.

Eventually, they’re going to need some technology arm. Again, I don’t want to recreate the wheel here, but I also don’t want it to be limited. I want this to be a setting of care that is mainstream. If these big players are going to launch hospital-at-home programs, I’m not mad about it. More patients will be able to access this kind of care and it goes back to, “Why did we start this to begin with? because we had personal experience with it.”

Most of my senior leadership had years and years and years of experience treating patients and seeing the disconnect there. I am very happy that bigger systems are getting into this space. I think that it will be eventually one of the first lines of care. You’re going to need all of these big agencies that have a lot of patients under their service to be able to provide this.

Now, the questions on operations, management, how it’s different from traditional home health, the physician component and how it’s integrated, that’s all stuff we’ve created, and we’ve worked it out. So it’s all good for them to come into the space, and we still have this layer of, “Hey, this is how we set it up. This is our central nurse station. This is our 24/7 monitoring. This is how we do it.” And we can partner with them. We’re in a world of partnerships right now.

[00:21:09] Donlan: You guys have this breadth of experience and knowledge. Do people approach you on partnerships, or is that a future thing you’d be open to – for partnerships on showing others how to do this correctly?

[00:21:28] Samuel: Absolutely. Interestingly enough, we’ve gotten approached more by consulting companies that say, “Hey, we have agencies or hospitals that we consult for, and they’re interested in the space. Would you be willing to partner here?” Partnering with bigger home health agencies, we’re always open to it. My staff, my senior leadership, we’re not the type of company that believes everything has to be ours and ours alone.

We created our own way of providing this space. And we like partnerships. It’s also moving very fast, so that saves them time when they’re trying to launch something like this.

[00:22:21] Donlan: On the home health care side, what are the challenges, the opportunities, and what have been some key learnings there?

[00:22:38] Samuel: In traditional home health, there haven’t been many challenges. Utilizing home health nurses for acute care, though, the challenge was actually breaking some home health habits in the sense of helping them recognize these patients are actually under the hospital’s care. Now we do a full training program for all of our nurses that come on to take care of hospital-at-home patients.

We also have physicians trained so that there’s care coordination there. We use our own command center and a central-nurse station to be able to coordinate the right care. That is not typical for traditional home health, that you would have a live nurse station that is connected 24/7 for your patients. I think it’s just training up in a sense.

[00:23:33] Donlan: So, what’s next? Is there another service line that you guys want to get into, or is there something you really want to expand? What’s the next step for growth?

[00:23:53] Samuel: Well, we have always thought that there are two spaces in health care that have a lot of opportunity to improve care while not increasing costs – and chronic care management is one. I feel like we’ve been doing a pretty good job there. The other one is preventative care. I think we can identify some of these chronic care patients before they have to go to the hospital.

There’s a lot of preventative care that we can deliver virtually or in a hybrid model – half virtual, half in person. That is in our expansion path. That’s where we’re looking to go next, but we will continue to build out the hospital arm and chronic care management. But yeah, I would say preventative health, and outside of that, just continuing to develop our technology.

[00:25:08] Donlan: In terms of preventative health, what would that look like? Would that look almost like a home care agency, that non-medical care both virtually and in the home?

[00:25:21] Samuel: No. I would say preventive health as in you’re getting your blood work regularly. You’re having a physician oversee it regularly. If you’re needing medication, it’s delivered to your door easily. Things like that.

[00:25:34] Donlan: Got it.

[00:25:36] Samel: Not to cut out home care agencies at all. We will continue to coordinate care with them. I think we all know that people don’t typically go and get their bloodwork to look at their heart unless they had a heart attack. Things like that.

[00:25:52] Donlan: Do you have any other expansion plans?

[00:26:10] Samuel: We have a few hospitals that we are working with right now that would get us into about seven other states, and we’re hoping to do that. It’s sort of plug-and-play for technology, but really, we get in there and we see how the hospital operates, and what the community looks like, and how we can stand it up for each hospital independently. We could launch this program in any hospital across the country. On how fast we launch, it depends on how much resources we have in that area. Rural hospitals, of course, are limited with resources, and so that might take us a little bit longer just to stand things up and get the right people there that you need.

[00:29:06] Donlan: Jackie, thank you so much for the insight. That was wonderful. Thank you to the audience for listening in. Everyone, have a great day.

[00:29:23] Samuel: Thank you, Andrew.