Choice Health at Home started off with a few credit cards, five employees and an idea for a business.
Now, the Tyler, Texas-based company operates in 60 locations, four states and has over 2,500 employees.
As far as services, Choice Health at Home delivers what David Jackson, the CEO of Choice Health at Home, refers to as four legs of the stool — home health, hospice, personal care and rehabilitation services.
But having those sturdy legs to hold up Choice Health at Home’s stool is what has made the company attractive to investors and potential partners alike.
Plus, Choice Health at Home is bullish when it comes to growth. The company completed 9 transactions in 2021.
Ultimately, Choice Health at Home’s goal is to become a national company. For now, it is taking steps towards that by creating regional density.
HHCN is pleased to share the recording and highlights of our HHCN+ TALKS conversation with Jackson and Trina Lanier, the president and co-founder of Choice Health at Home. Read on to learn more about:
– Choice Health at Home’s modest beginnings as a company
– What Choice Health at Home’s leaders believe is the biggest challenge facing the industry as a whole
– How and why the company got involved with its private equity backers, Trive Capital and Coltala Holdings.
[00:00:03] Andrew Donlan: Good afternoon, everyone. Welcome to another edition of HHCN+ TALKS. I have two wonderful guests today that I’m very excited to have. We’ll give you all a second to come in, and then we’ll go ahead and do introductions. We have David Jackson, the CEO of Choice Health at Home, and Trina Lanier, the President and Co-Founder of Choice Health at Home. They are located in Tyler, Texas, one of the more rapidly growing home health providers in the country. We’ve written about them a lot on homehealthcarenews.com over the last year, so, I’m super excited to talk to them about that growth today. Let’s kick it off with some background for the audience.
David, can we start with you? Just your background, before we get into Choice.
[00:01:00] David Jackson: Absolutely, Andrew. Appreciate the intro. My name is David Jackson, I’m the CEO here at Choice Health at Home. I entered this business and industry as a practicing physical therapist. I love what we do, helping patients recover in the comfort of their home, and that was something that fascinated me about the industry. I’ve been in home health and rehabilitation services for more than 20 years. The most significant endeavor has been this company, I founded it in 2007. It really was a clinical journey for me and a story of taking care of my grandparents and seeing just how important that was and what that meant for families. It just really had an impact on my life.
As we continue to grow this business and our footprint, that continues to be our mission — to improve and enhance the care of those patients as we deliver excellent health care in the comfort of their homes.
[00:02:07] Donlan: Fantastic. Trina, some background on yourself?
[00:02:11] Trina Lanier: Hi, everyone. I’m Trina. I’m a nurse by trade. I got into the industry back in 1995 as a nurse. I, believe it or not, decided to go to nursing school. I’ve worked across the whole post-acute continuum with hospitals over the last 20, I guess that I’m dating myself, like 26 years now. In 2012, David recruited me to join his company, Choice Rehab at that time, and that is how we launched our home health services. I’m here at Choice now, continuing on the journey.
[00:02:47] Donlan: For the audience that may not know, can you guys give a background on how home health ultimately came into the picture? David, we can start with you, and then Trina can give her perspective.
[00:03:01] Jackson: As Trina mentioned, in ’07, I launched a rehabilitation service company. I was a physical therapist with three credit cards and a really bad line of credit in the middle of the credit crisis, and I had this idea of staffing hospitals. That’s how we started, then we moved into the nursing facility realm and very quickly picked up a few home health clients, and it was limited. The agencies that we worked with were people that I met. I used to joke that our contracts were negotiated over a plate of barbecue in the state of Texas and a handshake, and then we wrote everything down.
If you think about that time period, rehab was such a focal point of home health, was a focal point of the payer structures, and continues to be a focal point for our patients and for the industry. At that point in time, it drove so much about revenue and was in a little bit different place prior to PDGM. In 2007-2008, the Obama administration put in place the Affordable Care Act, which began to roll out around 2012. I’m a big believer in reading MedPAC, and the great thing about the system is they signal for about five years and then start to make a turn, in most cases. I started to see that this was potentially going to impact us as far as the idea of controlling a readmission.
Some of our hospital clients had already started to talk to Choice about like, can you modify your contract? The patient comes back in, because there’s just a lot of confusion. In 2012, because of that, we were like, we want to become directly interfacing with our patients as a provider downstream from our clients, and rehab and in the communities that we serve, and we built this network of therapists.
Again, even at that time, that gave us a huge advantage, and so I started to look around the industry and look for people who could help me, and had an understanding of my vision — we want to be on the full journey. A patient comes out of the hospital system and we want to assist them all the way. We used to say, I remember when BPCI came out, we were like, “Return to Target program, return to Walmart program,” like, we’re going to get back in the community.
That was why we started looking for it. We bought a single agency license and then would go down the road another hour and buy another agency license. The credit line got a little bigger and the infrastructure continued to improve. That was really – leading on into talking about Trina Lanier – that’s when we looked out in the industry, looked in our service region and were like, “Who is someone that understands that journey and has done Biz Dev operations?” And Trina met all of those requirements. We were just really excited to get her on board at that time and begin the home health journey.
[00:06:14] Donlan: Trina, why home health, and why do you feel like that was the right place for you to join the company and help lead that segment specifically?
[00:06:25] Lanier: Oh, what a story. My whole background as a nurse, I worked in the hospital and in the nursing homes. I developed a passion for the nursing home side, which is why I went to nursing school. As I came out, you could go right out of nursing school and the only way to really learn anything is just to get out there and start charging on the floor. As I was going through that experience early in my career, I was approached by what they used to call the MDS nurse and the director of nurses in the nursing home and I learned how the company was able to provide quality for the patient and get the patient to the right level of care post-nursing home stay. The last thing I wanted to do was see them go long-term.
I learned really quickly to work with therapists and physical therapists became my best friend. Over my career, from like ’96 to say, 2010-’11 when I was first introduced to David and his company Choice Rehab, I was taking patients from the hospital as a nurse liaison, all the way back through the continuum. I was very familiar with skilled nursing facilities, assisted living memory care, home health and hospice. I think, for me, it’s just always been a passion of making sure that patients receive the right level of service so they can get back on the golf course, or go on trips, or spend time with their family and live life to its fullest until it’s no more. That is why I’m in home health.
[00:07:58] Donlan: We’ll get into the specifics of the growth in a minute, but what has been the most difficult part of growing in home health, specifically?
[00:08:13] Jackson: If you think about the way that we were founded, at that point in time, nursing and therapy were probably running neck and neck. Therapy might have been a little bit ahead of nursing, as far as the staffing shortage because of the way the structured payments were. In 2012, we found this business and we had access to, at that point, probably 300 therapists with Choice Rehab.
We had this turnkey staffing advantage over any startup home health and infrastructure. The business at that point in time was probably an eight-figure business in multiple states, and we had very high density in our home health footprint. Fast forward to now, the staffing, I tell people, Google the most difficult part about home health, it’s staffing, staffing, staffing. I think that’ll be a continual headwind for the industry, and it’s probably one of the more frustrating aspects of the new pay ruling as we look to next year. It’s almost like, “Hey, do you see what we’re dealing with in staffing?”
I would say the two biggest headwinds to growing the business are the staffing restrictions in different markets, that is the hindrance. There are plenty of patients, it’s about if you can staff those patients, and then secondary to that would probably be the proliferation of the MA plans. They continue to be more difficult to work with than Medicare, a much more cumbersome admission process … We have to be very active in interfacing with those MA payers because of how complex they make the admission process and authorization for those patients.
If I was to talk and discuss headwinds, that would be the two components that I think are making it more difficult. That’s not isolated to Choice, that’s probably everyone in the industry right now.
[00:10:27] Donlan: Absolutely. David, before we move forward actually, can you give us the scale of the company right now, both overall and within the home house segment?
[00:10:35] Jackson: 2007 was five employees, when I got started, and now we operate in more than 60 locations, four states, over 2,500 employees. We have the home health service division, the hospice service division, rehabilitation services, and have just added private-duty, which we’re really excited about.
[00:11:06] Donlan: Fantastic. Trina, in terms of the Medicare Advantage aspect of this, have you ever thought about shying away from those patients for more folks on fee-for-service, or especially now with the proposed rule, is it just about advocating for better payment rates and figuring out how to be as efficient as possible when dealing with Medicare Advantage?
[00:11:30] Lanier: I’m going to go with the latter. We definitely need to be advocating with the MA plans, the companies, so we can provide better care to those patients that are out there, because they are being flipped from traditional Medicare literally every day, all day long. We’re finding that in pharmacies, even in some physician clinics, now, they’re setting up booths to do that. I don’t think we can advocate or lobby enough to work with those companies one-on-one. They’re holding us to the highest standard alongside Medicare.
To me, I don’t think we can do enough work there with those companies to provide a better rate for the home health services that we’re providing, so we can get out there and do more with them, not to mention the odd process that it takes just to get authorization to see those patients. It’s very burdensome on the back office and our clinicians.
[00:12:30] Donlan: David, you just brought up the proposed rule. When that first was announced, were you shocked, surprised? Obviously, you were probably disappointed, but what was your reaction, and do you have any comment, besides the staffing, about why it may not be a fair proposal?
[00:12:50] Jackson: I think I, along with everyone else, was somewhat shocked. If you think about the things that we had dealt with in 2020, we were already dealing with one of the most massive overhauls in payer changes in the history of home health. As you come through a pandemic, I tell a lot of people – we obviously are very active in mergers and acquisitions and so we see a lot of businesses, so it’s interesting to me. I learned in the different areas that we look for businesses to buy, we see the financial impact and ramifications of what went on over the last two years, to my point earlier on the staffing headwinds.
I just feel like the short answer was I was a little bit shocked. Now, what I tell people that I discuss this with is we have to advocate as strongly as possible. This industry’s going to be here. We’re going to be as efficient as we can with MA plans, we’re going to go aggressively in traditional Medicare but I think we cannot advocate enough for, “Hey, let’s look at the real-time information.”
If you look at your travel per visit right now, your travel cost — it’s excessively high. It’s 40%, 50% higher than they were six or seven months ago. We’ve got those things that are just not in the data that was used to develop this idea. When you’re looking at the cost of delivering care, I think most of us feel like this is a little bit too aggressive, or not a little bit too aggressive, very aggressive. It is important to be prudent with the beneficiaries and with the Medicare financial system, but I think we have to advocate against such severe rate reductions.
[00:14:57] Donlan: Trina, as someone that ended up being intimate with the home health space, do you feel like there’s a major disconnect still, even in 2022, between the home health industry and those that are outside of it? Whether that even be CMS, whether that be Medicare Advantage, there still seems to be this disconnect between the people that operate within it every day and the people that don’t.
[00:15:27] Lanier: Yes, we face real-time challenges every day and we’re in the middle of a pandemic. Pre-pandemic, education was an issue from home health agencies, hospice agencies, really just all health care service lines out in the community. Hospitals tend to do a better job at that, I guess, with the amount of advertising they can do with billboards and all that. I think the opportunity in home health continues to be, even through the pandemic, reaching enough folks in the community to share what our services are and what we provide, and the why around making decisions for family members, even if it’s to change a payer, to seek out a service, or just ask a question about the aging process and what their diagnosis is.
[00:16:14] Jackson: I would comment too and just say when you talk about our industry in general, to Trina’s point, advocating the community for what those restrictions are. When you have a booth set up at a local pharmacy that’s converting people, most of that generation would not select the MA plan if they knew the ramifications when they have a broken hip. Yes, it’ll save you $50 to $100 on your drugs, but when you break your hip, there are some significant ramifications here. Let’s talk about what you buy insurance for.
Additionally, as an industry, I think we don’t do enough to talk about, and going back to my reference of reading MedPAC, I’m always fascinated by how it silos out the different provisions of health care, and home health spending continues to increase as the number of 85-year-olds continues to increase in our country. When you look at it in a silo, yes, that is true. When you look at it in comparison with the other realms of service, even the traction that hospital-at-home has is indicative of people taking a step back and going, “Wow, this is so much more affordable.”
We talk about our own industry a lot, but I think one of the things that we really need to be vocal about is to look at ourselves. If we are providing more services in the home, how does it reduce spending in these other silos?
[00:17:46] Donlan: Absolutely. I think that’s been one of the issues actually. You can’t look at something like home- and community-based care as just in itself. You have to look at what else it reduces, the impacts it has down downstream and upstream.
On a brighter note though, the growth has been very impressive. You have said previously that you want to stay in the Southwest for now. Do you think that’ll change at any point?
[00:18:19] Jackson: Oh, absolutely. I think we’re vocal about that because we want people to know that we would be excited to talk to them about opportunities in that footprint. Reach out to us directly. We’re inquisitive in that footprint. Who doesn’t want to fly to Santa Fe at any point in time? I spent quite a bit of time in Phoenix. That’s why I’m a little red today because I spent quite a bit of time in Phoenix over the last few weeks and Scottsdale is great, but August and July is a little rough.
Through 2024, that’s really our focus. Ultimately, Choice does want to be a national company. I’ve looked at different businesses that seem somewhat spread out from a geographic perspective and I wonder. I’m a physical therapist trained as a nurse, managing multiple geographies without creating some regional density initially is not something that I want to endeavor on. I’m going to focus on this through 2024 with the ultimate goal is that we will pivot and we do want to be a national business.
[00:19:30] Donlan: Trina, how do you make sure quality remains the same as you guys grow?
[00:19:35] Lanier: Quality. It always has to be there no matter what you do. We just recently did a conversion to Homecare Homebase, which was huge for our company and the clinicians. It was a big decision going into the home health value-based purchasing year of 2023. I feel like education is the key for everything. You’re going to keep hearing me say, educate, educate, educate, but we cannot have enough of that internally in the company, as well as externally. Then SHP is another product that we’ve had as a part of our company since the beginning to be a centerpiece, to help us guide our clinicians and work with OASIS and ensure the quality is provided to the patients to get the best outcome.
[00:20:25] Donlan: You mentioned HHVBP, how have you guys been preparing for that? I assume education is part of your answer, Trina?
[00:20:32] Lanier: Yes, I think the same things there. Homecare Homebase, the value there and their product, the value SHP has being the centerpiece there, and then just, we’ve always focused on quality since day one. The very first patient, it was important for us to ensure that they have an improvement in their outcome, and if they weren’t improving, that we provide the resource and the education of what’s going on with that loved one, that patient, and what is the best level of service for them. In the end, it’s a part of that conversation when you’re trying to provide the quality.
[00:21:08] Jackson: When you talk about those changes to value-based purchasing, I think we stayed on certain software products because we knew the acquisition pace and the integration problems that would occur there. Anyone in our industry and anyone in health care will say that software conversion is pretty brutal, even with the best processes in place.
That’s been probably one of the most challenging things we’ve had this past year, making that conversion. I’m really glad that we did it prior to value-based purchasing. Once you get into value-based purchasing, the conversion is going to hurt you as far as quality reporting. It just is, that’s a fact.
[00:22:10] Donlan: How long did that process take you, if you don’t mind me asking?
[00:22:14] Lanier: In all, a year.
[00:22:17] Donlan: Okay. So it may be even a little bit too late for those that haven’t gotten going on it yet.
[00:22:23] Lanier: Get started now.
[00:22:25] Jackson: I think that length is when you start talking about the number of locations, I think that would be a much faster conversion otherwise. We had multiple waves.
[00:22:36] Donlan: Okay. Now your backers, Trive Capital as well as Coltala Holdings. I’ve spoken with the Coltala guys before. How did they become interested and why did you decide ultimately to take capital, David?
[00:22:53] Jackson: Well, the three credit cards ran out. The transactions in the way that we were executing were very entrepreneurial, SBA-type businesses. I had some great banking relationships in Texas, Louisiana and Oklahoma that allowed me to make progress as an entrepreneur. Coming into 2020, I saw the payer change. I was like, this is going to be very disruptive to the industry. I saw that as an opportunity.
I was looking at, we had entered the hospice realm in ‘18. We had home health, we had rehabilitation services and we had hospice. When I started vetting different firms, we were attractive because we had three different legs of the stool. Even in a payer change, like when you started running modeling, we were attractive because it didn’t really move the needle significantly on Choice, and we owned our own rehab.
When you start thinking about the ramifications of PDGM, they would say, “how do you feel this will affect you?” Well, we’re 97% in-house rehabilitation services, so we can pivot. I think when we looked at that and started vetting groups, naturally, Trive and Coltala, the geography of them being in Dallas-Fort Worth was attractive. I drive a Chevy pickup, don’t mind driving down the road to see those guys. That was an attractive item, and then several members of those firms had been in the industry before, and so that was also attractive.
Then finally, they’re not horizon funds, so we don’t have a point where I would be forced to have to choose another partner, like because of timing of a fund. I think that’s important when you start vetting capital partners is, hey, are you going to walk in one day and say, “Hey, this fund’s time is up. It’s time for you to pivot, David.” And that’s why I’m pretty firm on dates. There’s southwestern geography, 2024 is when I want to pivot to a separate growth plan from a geographic perspective, and that flexibility and knowledge of the industry made them very attracted to us.
[00:25:31] Donlan: Trina, why do you think they were attracted to you guys? Taking their point of view for a second, what were you guys bringing to the table?
[00:25:43] Lanier: I think we shared values of creating a positive environment for employees. Our focus was on quality and delivery of that quality, and then just a drive to grow our business, and they met all of those needs for us. I work for an amazing CEO right here, so he is definitely somebody that expects the best, wants the best, not just for his employees but patients all the way out across the continuum. I think Trive and Coltala recognize that value in us, and they shared the same beliefs, and here we are today.
[00:26:27] Jackson: When you talk about private equity and if people are looking and interested in that, my advice on that piece is, we had a three-legged stool, we had rehab, hospice, and home health. One of the things private equity is looking for is, is there a threat? You think PDGM’s coming down the pipe in home health, but we have these two other legs of the stool where the revenue was very consistent. No matter what, as you choose a capital partner, you want to present your business and even if you are single-line home health, you can say, “Hey, this is what we do well. We know what we’re doing. That’s why the threat is less.” They’re going to want to minimize risk.
Then the second aspect after minimizing risk, because that’s how they get past investment committee, is answering the question of how do we grow our investment? There’s a lot of talk in the industry about private equity and their role in health care, but I can tell you that the financial support and the ability to make a Homecare Homebase conversion. That financial impact for a company that has as many employees as ours, I could not have done that as an individual. It just would’ve been very difficult. My mother’s a school teacher, my dad works in the oil field and three credit cards don’t pay for that.
They provide that infrastructure but they do want to know what the growth plan is. Is it organic or is it M&A? If you want to build a great sales team and show a growth trend, and/or you want to have targets under LOI. I believe when we recapitalized, we had four targets under LOI, including a joint venture with the University of Texas that I believe now is one of the largest home health joint ventures in Texas with their hospital system. We had a growth story, both organically and through M&A, and that’s attractive because private equity does want to grow their investment.
[00:28:18] Donlan: For private duty, your newest segment, that’s also got to be good for diversification moving forward. As the proposed rule and the final rule looms, it’s just another segment that you’re able to grow and still diversify.
[00:28:34] Jackson: You’re talking to a nurse and a physical therapist at our core and I always talk about the clinical journey. For me, home health was just natural, like, this is where a patient wants to be. I want to teach him how to walk better, get back to the target. Hospice was a progression. My grandfather left the country one time and it was to go to France because there were too many Germans there, and then he came back and his experience in hospice was really rough on my family, and so I wanted to improve that. I saw that as like, “Oh my goodness, as a PT, I haven’t been treating that part of the patient, so we need to move into that.”
If I can get Ms. Jones a meal and help out five days a week, how much better can I make her life and improve her function? That’s just the PT in me looking at that. I get excited about that clinically and that add-on. We had begun dealing in that space, and then finally, when you start looking at it from the business aspect, it does create a certain steadiness of revenue.
[00:30:38] Donlan: Trina, anything to add before we move on?
[00:30:40] Lanier: No, he covered it all well.
[00:30:43] Donlan: Okay, so David, you just mentioned that you’re very time oriented. You have specific deadlines for yourself, specific dates that you want to make the next move. Where do you want the home health business for Choice to be, in let’s say, five years?
[00:31:03] Jackson: We want to be recognizable on a national scale in five years. Obviously, when I started, you hear me talk about the three legs of the stool as we started and now we’ve added this fourth leg and we really feel like that makes us a much more complete business. From the home health segment, we want to be in every market that we’re in geographically. If we have a hospice segment there, we want to have a home health segment, we want to have private duty. We want to offer rehab services, and for home health specifically. Home health is the centerpiece. That’s what’s great about what you guys write about.
Home health is this hub and we can impact so many other sectors; hospice, the hospital, inpatient skilled, inpatient rehab, home health is the centerpiece, so it is just imperative that we offer those services in every geographic location that we serve. We want to be an employer of choice, no pun, but that’s a challenge when you’re growing. It’s a challenge because you want to try to push forward the values that made our business grow and make us Choice, so that’s the challenge that we have to engage in order to do that, so, very excited about the next five years.
[00:32:29] Donlan: Trina, from your perspective, in order to be the provider of choice for prospective employees, where does education come into that? How do you think you can retain your education?
[00:33:03] Lanier: I think when you’re working with employees, the best delivery of education for them is to make sure they have the resources and the tools they need at hand when they’re providing that care for the patient, software that’s user-friendly, quality software that tells them where I’m doing well, where I’m not doing well, that you can put in front of them.
Leave always educating on room for improvement because I don’t think there were any of us go out there and deliver perfect care every time, but learning from our experiences and continuing to have that open communication and collaboration across the continuum is how we drive education and we make it fun and exciting, not just “Here we go again.” Because in home health, it is sometimes “Here we go again,” especially when CMS starts getting involved.
[00:34:21] Donlan: Okay, fantastic. David or Trina, anything else to add that we did not touch on today?
[00:34:30] Jackson: I think I’m very excited about our industry and the direction that it’s going, the new rule notwithstanding. We pushed so far with tech and even some of the waivers that they put in place during the pandemic and I feel like we just need to stick our foot in that open door and be like, “Hey, this really worked.” Even like the use of nurse practitioners, some of the tech advantages that they gave us, this is not something we should go backwards on. We need to push to codify those changes as an industry. It’s exciting because it opened the door in the eyes of so many people like, “Wow, this is a whole lot better place to receive my health care.”
I think back three years ago, talking about having a remote patient monitoring arm and talking about telehealth and getting people just to use their phone was so difficult in this demographic. Whereas, fast forward three years and everybody’s like, “Hey, I want to talk to you on FaceTime. Let’s do some FaceTime, let’s do some Facebook messaging and stuff.” It’s a great time to be in home health care and that’s what I would close with. It’s a super exciting industry for anybody’s just getting into it. I love what I do every day. I think Trina feels the same and we want to encourage people to get in.
[00:35:53] Donlan: All right, well, Dave and Trina, thank you so much for joining us today. I really appreciate the time and the insight, and I know our audience is going to enjoy it.
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