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Is there a single right way to run a home care agency? We sure don’t think so. That’s why we’re interviewing home care leaders across the industry and asking them tough questions about the strategies, operations, and decisions behind their success. Join host Miriam Allred, veteran home care podcaster known for Home Care U and Vision: The Home Care Leaders’ Podcast, as she puts high-growth home care agencies under the microscope to see what works, what doesn’t, and why. Get ready to listen, learn, and build the winning formula for your own success. In the Home Care Strategy Lab, you are the scientist.
Miriam Allred (00:00)
Welcome back to the Home Care Strategy Lab. Today in the lab, I'm joined by Jamie Arber, the executive director at the Supported Living Group in Connecticut. Jamie, welcome to the show.
Jamie Arber (00:12)
Thank you.
Miriam Allred (00:13)
You and I have recently got connected from mutual acquaintances in the industry and I've learned a lot about you and about your organization recently. And so I wanted to have you on the show to unpack really your business model. I just said this to you before we got on. You're not my typical guest, but I think what you all are doing and what you've accomplished is really interesting and relevant to home care companies that are looking to branch out and diversify and figure out how to become kind of a comprehensive solution. So
before we get into your business model and into the weeds, I want to have you introduce yourself. Your career path has been pretty fascinating from England to the U S from psychology and marketing to becoming the executive director at I believe what is Connecticut's number one provider for brain injury support. Tell us a bit more about your background and your journey getting to where you are today.
Jamie Arber (01:02)
So I grew up in England in a very, very working class family. I was the first member of the family to go to university and I specialized in psychology.
That was my piece. I really wanted to help people. And my mum had worked in the caregiving field. She was a caregiver, but in the school system, working with individuals with intellectual needs. So I had graduated from the University of East London and was offered the chance to come out to the States. When I landed, it was interesting because trying to find a job in the field was very, very difficult. really wasn't, you know, I've got a degree in psychology, but the reimbursement,
like
getting paid wasn't looking great. So I ended up getting a job in sales and marketing for a very prestigious and high level company, Elise Van Breen Antiques. They specialize in Swedish antiques and interior design. And they're very well known in Connecticut and Nantucket and places like that. So I was working for them for a number of years and the owners of that company were always pushing me to go back to school to get my master's degree. So I did, I went back to
school to get my master's degree in community psychology. And in 2010, the housing market crash happened. And when the housing market crash happened, not many people were looking for Swedish antiques and interior design services. So that was my opportunity. I just graduated with my, my master's and I had applied for a few different positions and I was, I had two job offers on the table. I had a hedge fund in Westpool doing HR and I had this little
and Pup operation that specialized in brain injury in Southbury, Connecticut. And something really spoke to me about helping people and working with people rather than babysitting people. And I chose the Mom and Pup operation at a significantly lower salary, but it was something that interests me. Even going for the first interview, nobody knew what to do with me. I had no tie at all. They kind of just gave me an office and saw how I wanted to see how it went.
and within the first month the director had quit. A month later the assistant director had gone out and worked as comp and I said, why don't you have a go at it? And it kind of went from there, to be perfectly honest with you.
Miriam Allred (03:27)
Amazing. How old were you when you came to the States?
Jamie Arber (03:29)
I originally came over when I was 19. I spent three years here. My sister offered me the opportunity to come over. They sponsored me and I went to Western Connecticut State University. So I did three years, then went back home for two years to finish up my degree in England and then came back over permanently in 2005. I mean, sorry, 2005.
Miriam Allred (03:52)
There
we go, there we go. I was like, wait, I've got my dates wrong. And then I was gonna ask how long you've been at the Supported Living Group then now.
Jamie Arber (04:00)
I joined
the Supported Living Group in 2017.
Miriam Allred (04:04)
2017 amazing. I think you're the first Brit that I've had on the show, which feels like a big personal milestone. I listen to a lot of podcasts and I listen to a lot of ⁓ guests and hosts from Europe. And so you're my first, which is always just exciting for me. So I'm excited to learn more from you. What a great story. ⁓ And now here you are seven, eight years in this role. And it was kind of baptism by fire. Like you just shared,
You had education and experience, but this was net new to you for sure.
Jamie Arber (04:38)
For 100%, I feel that the sales and marketing piece, working with very high end clients with high expectations and the relationships that you have to build benefited me. I was kind of a wild card thrown in and meeting with referral sources, how you see me dressed today is how I dress. I'm typically in a suit or I'm in a blazer shirt and tie. That made a world of difference in the field. It was kind of interesting to see
how those referral sources respond and also, you your word is your bond. That's kind of how I work. So if I say something's going to happen, it's going to happen. And that was something different as well. So very rapidly, all of a sudden, when I was working for that mom and pop, the referrals started to come in. ⁓ We became more professional and we grew. mean, within a three year period, we'd grown to the largest provider in Connecticut for brain injury during that initial first three years ⁓ prior to.
and moving on from that agency. And it was a great opportunity. I learned a lot. I learned what to do and what not to do in business. And I also sitting there looking at the brain injury part, how services could be improved with the right structure that was in place if the investments were done correctly. And that's something that's benefited me for a long time as well.
Miriam Allred (06:02)
So you're already referencing this brain injury support. And so I want to have you explain the business model. explain what their core service lines and what their core kind of business model was back then that you were walking into.
And then we'll fast forward and kind of talk about like the transition, the growth, the evolution, but what was the business structure that you were walking into?
Jamie Arber (06:24)
So I was asked to join the company by Christopher Brisson, who is the president founder and his wife, who's the vice president, Kimberly Brisson. The company was mainly based in Eastern Connecticut and the main...
payment models were Medicaid, ABI waiver. And then we also had some private pay business that had occurred, but was more specific towards brain injury and workers comp. But those came along, those were very, very rare fishes that come along once in a while, if you know what I mean. So there was a small number of clients around 11 clients and it was mainly in Eastern Connecticut at that point. So when I joined Chris basically,
said to me, what do you need? I said, I need a building. If you can give me a building, then I can build, I can develop the rest out. And we spent a little bit of time looking for a location in Western Connecticut. And we found a spot that was very industrial, which most agencies, why were you looking for an industrial building? And the reason was because I knew I could build out a creative arts program. And I'd had success with that in the past, as well as adding in some new components that hadn't been there before. So we, we
had a we we had an industrial arts program as well as a creative arts program. What we did there was expand us. We had the Medicaid waiver, which was brain injury. Again, we had a cluster of individuals that were coming referral sources again, referring into us. And over a period of time, we started to develop our PCA waiver and again, another Medicaid, but a different service line. And then we were always available for private pay sources. And we had a couple of
clients that had come from our referral sources which were legal entities that had had long-term care opportunities and they were managing trusts for those individuals. So that's kind of how we started to grow and we grew rapidly. We outgrew that location in a year pretty much.
Miriam Allred (08:31)
So you said it, a lot of operators come to you and say, why the building? Why the programization? I think that's my question as well. To make sure I understand, you were taking care of these clients out in their homes, but you wanted a building to build out programs as a differentiator, but also as a way to serve these clients in a more meaningful way. Is that the premise?
Jamie Arber (08:43)
Yes.
Within the acquired brain injury field. There are specialized agencies that only do brain injury. There are other agencies that more home care based that provide services in the residential locations of each and every client. What we had looked at as a business model was by providing these specialized services, you develop longer term clients.
because you're giving back a sense of purpose and it also reduces down any competition coming in and taking the clients from you because unless you're able to offer something very similar.
you're not going to leave the agency to go sit at your house and not doing anything. The other piece to consider is the vast majority of individuals that we provide services to under the Acquired Brain Injury Waiver Programme are 24-7 in nature. These are not four hours, three hour cases. These are 24-7 cases where you've got to come up with something rather than sitting there looking at each other in the face all day long because that's when you start to have the behavioural issues and
it becomes very problematic. Enabling an individual to re-find and re-discover a sense of purpose, I think is huge. And that's where the program locations enabled us to do that. And the creative arts that we incorporated in is also therapeutic in nature, as well as skill building, as well as motivating, and it also allows a social element to go on. Individuals are making friends. That's another reason why you don't want to leave the agency because your friends are there. You're doing stuff on the weekends with your
other. We've had individuals meet and program, get engaged, live together and we've supported that. So those are some of the success stories but that ties in with the business model because the acquired brain injury waiver in Connecticut you can go on to that waiver at age 18.
And when you leave the waiver, it's a lifetime waiver, is when your medical needs go beyond what is deemed community based. So you're needing a system to do ADLs and elements like that. So in terms of building the brand, in terms of financial security, making the investments in bricks and mortar is something that's fundamental to our business model.
Miriam Allred (11:12)
Okay, lots of follow up questions. Let's start talking about just the, the creative arts program, like the programs themselves. So you do have some psychology background, but how did you go about building these programs? Was that something that you personally figured out? Did you hire people that had experience in this? Like, how did you actually start to like build out that program?
Jamie Arber (11:15)
Yes.
So the first agency that I fell into the field in in 2010 had an arts program, but it was very, I would call it like infantile. was, you you're sitting there with coloring pens and, painting by numbers and stuff like that. And it drives me nuts because we're dealing with adults and with brain injury, it's not developmental differences. Each one of these individuals had a life before the injury. Again, most of the individuals sustain their injury after the age of 20.
perfectly honest. We have service participants, clients that were doctors, lawyers that owned businesses and then the brain injury happened. So what I wanted to do was offer something very, very different to what was in place before.
when you're in the home care field, you meet a lot of home care people, right, who have a very narrow field of vision in terms of how services need to be provided and what worked previously, you know, we can just repackage it and redo it again. So.
By bringing in artists, meeting artists, there's these wonderful creative minds that look at programs and opportunities in a completely different way to what I would think about or any of the competitor agencies. So you have to manage the ego and the creativity, which, which might think my psychology background comes in helpful with, but allowing these individuals to come into the program, interview them, train them to work specifically with individuals with disabilities, but then let them loose with their ideas.
So within that, I mean, in terms of programs that I've developed, we had a motorcycle shop called the Beastboat program because there was an older group of clients that were coming through that had gone through technical school and wanted hands on, know, they're grisly old guys that if you're to sit there and go, let's do a painting project, they're going to look at you like you've got four heads. having the hands on piece and when you build programs or when you have an idea of programs, I think the universe kind of brings people to you.
So I had two bikers ⁓ who were the people overseeing that program. One of the bikers was a brain injury survivor themselves who was doing well, no issues or anything of that nature. But they came in and were able to work with the individuals. They told me exactly what they needed in terms of shop tools, elements like that. And that program was generating a good amount of income just on its own and bringing in clients because nobody else had anything like that. ⁓
creative arts program, why we were looking for buildings to house our location. I had walked into a spot and there was all this amazing woodwork and the gentleman who was showing us around the super of the building, I asked him, who, where, where did this come from? ⁓ I, I created it. So I was like, tell me a little bit more about yourself. So I was a technical teacher for a number of years. I secured IBM awards while I was teaching because I was using
Do want a job? Yeah. And we brought him in and he was teaching fine woodworking skills. And again, these are programs that nobody else is offering. But when you have a client that comes in and is going to make a decision between your agency and another, and the other agency is just offering standard home care.
they're going to choose us each and every time and they're not going to want to leave because they've got purpose every day. They're learning new skills and when they create that first creation and they've got something to show, you see the sense of pride because for some individuals, it's the first time they've done anything since their injury. So that's part of the business model that we put together.
Miriam Allred (15:16)
This is really neat. And you said it towards the beginning. These are 24 seven cases and a caregiver in a home with someone with a traumatic brain injury. What do they do all day? You know, you don't want them just sitting staring, like wondering what they do. So this was born out of that necessity to give them opportunities to get out of the house, to do something creative, to bond with like minded people, similar background people. Like I just think the structure is so neat and has been so impactful. And
You've got so many different programs. already highlighting like just these programs get born out of ideation with the clients themselves. And now it's evolved into a very like robust program with a lot of different specialties, which is incredible.
Jamie Arber (15:57)
It's also quality assurance. for the agency owners, if you have a client that's, let's ⁓ say, $300,000 a year contract, you want to lay eyes on that individual. You want to make sure that the services are going well because losing that revenue stream could impact multiple individuals within the agency. So having the program space, I get to lay eyes on the individuals. I know all of our brain injury clients.
by first name. I interact with them, I talk with them on a day to day basis. The owners of the company are interacting with the individuals. There is no ivory tower management. It's just that philosophy. It started as a family feeding agency and we've kept that in terms of the conservators that we work with have my cell phone number, have the owner's cell phone number, we're reachable. ⁓
And it definitely allows us to make fast decisions if there's behavioral problems or if we're noticing, you know, John's not shaved for a few days, what's going on? I can actually interact with him. And that also then led to the development of our clinical side of the business because we wanted to be able to respond to problems promptly and quickly in order for stabilization. Because in that brain injury field, if there's problems going on, that's a risk factor to that contract. Because if you can't manage that
individual behaviorally, that contract's potentially going to go away because the family are going to become frustrated or the conservator is going to become frustrated. So that's why we ended up moving towards having a neuropsychologist on staff. We have OTs on staff. We have a board certified behavioral analyst on staff because that's an important component to have.
Miriam Allred (17:38)
You make a really good point too in traditional home care, the caregivers out in the home, the eyes and ears on these clients, but sometimes the office staff, the clinical team, the leadership team is removed from the care that's taking place, removed from the needs of the clients. And it's all relayed through the caregiver and not to say that they're not doing a great job. And they are again, the eyes and the ears. But what you're saying is this gives the leadership team, the administrators, the psychologists, the opportunity to have face time and interaction with.
your clients at scale because a part of the issue too is, you know, for a small office with 20 to, you know, maybe 50 clients, it's possible to still have that FaceTime, but you get to hundreds, thousands of clients. How can everyone have that type of FaceTime and interaction? And like you said, to drive decisions, you are more nimble and responsive because you are getting that FaceTime with your clients in mass. So you can make decisions and, kind of transform the programs as needs arise.
Jamie Arber (18:34)
responsive is key to everything that we do. And I mean, the other piece is since the pandemic, the caregivers, prior to the pandemic, you were getting a different range of caregivers. we've seen it. mean, across industries, across states, I watch your podcast, I listen to your podcast. the
The thing that comes multiple times is the turn and churn in terms of caregivers. So if you have that on cases, it's difficult to communicate out ⁓ the culture of the company, the expectations of the ownership team and the clinicians. But by having these locations, these bricks and mortar sites, those staff members are potentially bringing the individuals in.
they're learning more about the culture, they're feeling supported, and they're potentially having the ability to interact about problems that they're facing, not only with their program managers, but with the executive team, with clinicians. And at that point, they're learning how better to serve their participants, secure and stabilize their employment, or if there is a problem.
we can act far quicker because we're seeing that the client isn't interacting well with the individual or that person doesn't have the right mindset or just the personality match is incorrect for those two people to be together and we can make an adjustment quickly.
Miriam Allred (19:55)
I want to ask some more technical, like kind of nuts and bolts types questions, which I want to start with how you package and sell this because you have the care that is taking place under the waiver and you're getting paid through the government. When it comes to these programs though, are those additional fees? Are those private pay? How do you basically package these services and how are they being paid for?
Jamie Arber (20:22)
So under the waiver program,
Pre vocational and supportive employment opportunities, can be, which are either one to one, or they can be done under, under a ratio in terms of supportive employment. Prevoke is one to one and even independent living skills training can be done in these environments. So those are higher reimbursables. So they can be done in these environments because you're teaching independent living skills, you're teaching socialization, you're teaching hand-eye coordination, you're teaching all these different pieces. For the private pay model, it's packaged as
as a specific rate. If you're going to be coming in and utilizing these spaces where these programs have been designed and developed, there's a rate there that we charge per hour for the individual to come in and utilize the space and the caregivers around that, the specialized caregivers that are in the space. And that's proven very, very beneficial for the agency.
Miriam Allred (21:19)
So to make sure I understand on the waiver side, let's talk about kind of the Medicaid side, the waiver side. The waiver is covering both the care in the home and these programs.
Jamie Arber (21:20)
Yeah. Yeah.
Yeah, the waiver is covering both the care in the home and programs that are in the community.
because it's a home and community based waiver program. So there's services in the community. Now the supportive employment element was some individuals work competitively in the community. They've got jobs at the supermarket. They've got jobs maybe at the bank doing like general maintenance or cleaning tasks, that type of thing. But some individuals that's not going to be appropriate for. So in terms of our creative programs, we've developed ⁓ the big arts piece of the program.
that we, in the long run, what I'm hoping to be able to do is have that as a standalone business where we're selling artwork to local businesses, we're creating displays and then changing those displays up on a monthly basis for a monthly fee, but we're able to pay our participants already competitively to produce that artwork that we can then sell. So that's another business element that we've lined into it.
Miriam Allred (22:36)
Speaking of the financials of this, explain how the finances of this look from kind of like a backend business perspective? Because someone hearing this may think, to get a brick and mortar location, to bring in teachers, trainers, to execute these robust programs probably costs a lot of money. So can you explain the financial backend and how that makes sense?
Jamie Arber (23:03)
The back end, if we're talking about waiver reimbursements, there are different levels of care within the Connecticut ABI waiver program. So they're designated to each individual based on their needs, whether that be physical needs or behavioral health needs. And there's also some mental health elements.
So
an individual on that program can go from anywhere, level one is around about $60,000 a year if they're the entirety of their budget, to a level four where there is no cost cap really, but you're typically around about $300,000 to $350,000 a year.
So you're taking profits off of that and reincorporating it back in for the bricks and mortar. But as I said before, if you're you're investing in bricks and mortar, you're solidifying your ability to maintain that contract, that client for the lifetime of their support needs. And you're reducing down that client wanting to leave to go to a competitor. And that's
That's a what for me, that's that's a wise investment to make. Because while that individual is in, if you're just doing straight home care services where you're in the house, the ability for that individual to move to another home care provider is is huge. And what we've seen since the pandemic is a lot of providers have actually given up their bricks and mortar and gone back into that home care model, the straight home care model. And they're failing at this point.
We are seeing it's becoming far more of a struggle. Their quality assurance is really, really low. And that's why our referrals have gone up since the pandemic. We grew during the pandemic. We were one of the only agencies to grow during the pandemic because we had specific locations that we were able to manage and maintain. were able to eyes on with our management team. Some people work great from home. Some people don't.
In the human service field, in my experience, the teams that we have were better in a building being let. Because it was kind of everybody was...
was kind of like ships without a mast, if you know what I mean. So being able to sit down, being able to have discussions and being able to work collaboratively to fix problems was super, super important. we have, so we have a location in Avon, Connecticut now, one in Bethany, Connecticut, and one in Danielson, Connecticut. So even the teams interacting ⁓ virtually was super important, but they were in the buildings making sure that we could continue providing services. And during that point, that first round of the pandemic,
first year. don't think we had one positive
case of coronavirus. We worked very, quickly to change our policies and procedures in terms of shift changes that were occurring in the community. When individuals are coming into the program space, we had specific protocols that we developed. We actually based it on European education systems and universities and how they were managing things. The owner of the company
went out and secured, like basically developed a food pantry because we didn't know if individuals are not going to have access to food, toiletries, these types of things, invest the company's money in setting that up because that made a huge difference. There was nobody else was offering that. So we had that in place. And I think that's kind of the methodology of the agency. We reinvest in the programs in order to continue growing.
Miriam Allred (26:46)
You made a lot of really good points in that comment. And I agree, you all are investing in specialization and differentiation. And in turn, you get retention. You're retaining these people year over year over year, because like you said, there's no reason for them to go elsewhere because elsewhere doesn't have these programs. And so it's a lot of investment and time and money into these programs and into this structure. But in turn, you're retaining these people for a long time.
I want to ask one question. You were sharing those rates of kind of like 60,000 to maybe 300,000, depending on the different levels. Is that specific to the ABI waiver or is that waivers in general?
Jamie Arber (27:21)
So the ABI waiver is a little bit different. As I said, that's kind of our anchor service and allows us to have the buildings and that's part of our model. And then we bolt.
on other services. So from that anchor service, which is the, the ABI waiver program, we're able to build our private pay for brain injury, which is very specialized because if you think, you know, the waiver program is reimbursing at that workers comp reimburses at higher rates,
There are private insurance that reimburses a higher rates because the cost of care is expensive. It's specialized, even though it's not medical, it's still specialized because of the behavioral health needs of this population. And again, we go back to its lifetime.
Miriam Allred (28:05)
Let's talk a little bit more about Medicaid. You said this before we got on, but Medicaid is kind of a dirty word in this industry. Why is that?
Jamie Arber (28:12)
Yeah.
Because it's a battle, especially in Connecticut. I Connecticut, the reimbursements are lower than any other state in New England. And in home care specifically, it's very, very difficult. Connecticut, it's a struggle because
There was a big push for self-directed care, which a lot of those individuals are unionized. The union in Connecticut has a collective bargaining agreement with the state. So union rates are far higher than agency rates, although agencies have all the oversight expectation and quality assurance expectation. So it's very difficult because if you're trying to hire staff in a traditional home care setting, let alone brain injury waiver,
you're competing with self-directed where they're paying potentially $10 to $20 more an hour for exactly the same service you're going to be paying for your staff member. And obviously you've still got to take a piece of that in order to cover your overhead expenses. so, we're a business, you've got to still make some profit somewhere. So that's the difficult part in Connecticut. I'm part of the Home Care Association of America's Connecticut chapter, the DSS.
committee and that's been a big piece. We keep pushing for higher rates just in keeping with the cost of living. There was a rate increase recently, but that was again in keeping with the cost of living rather than the reality of what you're doing in terms of providing services. And we've got to get this fixed. Medicaid has to get it fixed across the country because even at private pay, at some point, the cost of living is going to go to such an extent that the savings of individuals
isn't going to be able to tolerate the pay of what you're to have to pay your staff. So there has to be somewhere in there a safety net for individuals because you shouldn't be burning through your savings as somebody in their 70s or 80s in order to have a service provider come in and provide support. It's going to break at some point so the quicker we can at least get Medicaid, Medicare to a reasonable level.
for businesses to be sustainable based on the administrative expectations and the quality assurance expectations the better.
Miriam Allred (30:31)
For someone that's listening to this, that we say the term Medicaid waiver and that's kind of a black box. don't understand exactly how they work. Can you share just kind of the key components of a waiver specifically and take ABI for example, like you think in that lens water, the key components of a waiver.
Jamie Arber (30:49)
in Connecticut, the acquired brain injury waiver, it's a 50-50 match. So the state government paid 50 % towards the expense and the federal government paid 50 % towards the expense. And the reason the waiver programs are there is because it's far less expensive to provide services in the community than it is to provide services in long-term care institutional settings. Plus the state started to realize that having an 18, 19, 20 year old in a nursing home
after the sustained brain injury was not great for anybody.
because the behaviors that were occurring were very, difficult to manage there. And what was the plan? They were going to stay there for the entirety of their life. So state and federal government work together to come up with specific regulations for services, as I said, for Connecticut and the acquired brain injury waiver to program. There are services such as companion homemaker, recovery assistant, independent living skills trainer. And then you've got your vocational, pre vocational supports, supportive employment. And then there's
CBT, Cognitive Behavioural Therapy.
That's your line items or services and they all come in at different rates. So as a provider, you're able to provide support services underneath those rates. Each line item of those services has specific language associated with it. How many hours you can provide per day. And that's essentially it. It's very in terms of private pay, it's like a service contract, but you don't have a contract with the individual. They're not signing a contract with you. You're essentially provided signing a contract with the state to
say
I'm going to provide these services for this individual who's being funded under your waiver program and the individual can leave at any point so that's why you've got to continue providing good care.
Miriam Allred (32:39)
Excellent. And my next question is when we think of private pay home care, there's low barriers to entry, which is why a lot of people are doing it and more businesses are opting in every single day. You just maybe indirectly answered this, but with Medicaid waiver, there's just more barriers to entry, which turns a lot of providers off. What are in your mind those barriers? Why aren't more people servicing these contracts?
Jamie Arber (33:04)
The biggest barriers is the reimbursement. if we were starting out on the waiver program now, I think it would be a struggle to be perfectly honest to to devote because in order for this agency to provide supportive employment services and pre vocational support services, we have to have a.
a contract also with the Department of Developmental Services to provide those specific services or the department, the Bureau of Rehabilitation Services. If you're just going in to provide straight companion and ILST services, you're going to struggle because there are already established waiver providers that are in place that want those hours and they're not going to give them up. They don't like sharing. And unlike the home care
model where it really isn't that competitive.
because there's so many clients, the acquired brain injury waiver, there's a finite number of clients. There's a finite number of slots. there's around, there's under 500 slots on the waiver in Connecticut. It's a closed waiver program. New York, is, it's open. Massachusetts is open. So Connecticut is very, very competitive. There's an eight year wait, six to eight years wait list to get onto the program for the brain injury piece. For autism, it's a 10 year wait list to get onto this program in Connecticut. Just because
the costs that are associated with it. So the brain injury community, it's very cutthroat. People hold onto their clients for as long as possible. There's a lot of shenanigans that go on. We've seen that. And stepping into the home care field in Connecticut, completely different.
agency owners are collaborative, sit down, you know, have a cup of coffee, talk about some of the problems that are going on, talk about rates. I think they understand it's far better to work collaboratively to come up with a solution that benefits everybody than to sit in a silo and try and get your needs met because it's not going to work. And recently I was at a provider council meeting for the brain injury piece and kind of said we need to do something differently. But
Nothing happened because people are still stuck in their silos. And I think in the long run, for the independent living skills training under the brain injury waiver, for example, there hasn't been a rate increase on that service since 2014. And you think anything that we're all paying more for our cell phone bill than we paid in 2014. I know I'm paying more for milk and eggs than I did in 2014. So why have we not increased that? We need to be going and lobbying
as a unit, as a collective to increase those rates because we don't, by not doing so, we're leaving ourselves vulnerable. So that's another element where I think a lot of home care agencies that are more specialized in private kind of look at these waiver programs and scratch their heads and go, why are going to give ourselves all this hassle of oversight and lower rates than just sticking with the private pay element?
And I understand that for us, it works because we we're specialized in the ABI piece and we know how to make it work, how to make it work financially. But then with that, we've been able to bolt on the other programs, the elder care programs, the PCA programs, the private pay. And if we're
You know, somebody comes up in Avon, we have a 20,000 square foot building that sits on 6.4 acres of land. And we have a horticultural program, the arts program, all these different elements. So if we have a workers comp case that is a significant case, well, as soon as they walk through the door, they know this isn't your normal, mom and pop operation. This is a big agency. Why don't you sit down with our PhD level neuropsychologist? Let's take you for a walk through the gardens. Let's take you for a walk into the creative program.
program, let's talk to some of our participants. Straight away, ⁓ we've got a competitive edge against anybody else in Connecticut. we've done that in Avon, we've done that in Bethany, and we've done that in Danielson. And I think even... Yeah. Yeah, go ahead.
Miriam Allred (37:14)
Really well said. Yeah,
really well said on just there's kind of three things standing out to me. You said like the rate is kind of that initial barrier to entry that turns people off. But then second to rate, there's just this level of like operational sophistication. Like this is not, you know, a cakewalk operationally. There's just a lot of moving pieces to it. And so there's just this level of again, like sophistication, the words coming to mind operationally to be able to handle something like this.
Jamie Arber (37:36)
Yeah.
Miriam Allred (37:43)
And similar just to Medicaid across the board, it's a volume game. You have to be able to do this at scale and to, like you're saying, bolt on these additional layers that make it financially viable as a business.
Jamie Arber (37:56)
in the home care field, VA contracts are lucrative for individuals. So that's when we.
probably going to be going to in 2026 is moving towards VA services as an additional bolt on because we're already geared up for it. We have our neuropsychologists and our clinicians already in place. We've specialized in brain injury, which a lot of that VA population have, and we've got staff members that are specifically trained.
As the executive director, my background, my psychology, I specialize in EMDR, hypnosis, all these different things that we can offer different to a standard provider that doesn't have these components ready to go. So the startup costs that you're talking about for, let's say, a home care provider that wants to start at exactly the same point, we're both entering into the field at the same time for VA services. We've got all this infrastructure behind us. And I think for us, we can pick this model.
up and drop it into any state, into any area.
and make it work. You don't need a 20,000 foot building. You can start it in a far smaller scale, but you can look at the waiver programs. Is there an ASD waiver? Is there an ABI waiver? Because we know what we're doing there. All let's start providing services there. We can do home care. We know we're at that. And we've got the reputation in other states where family members or referral sources can reach out and say, happened here? And it's all been organic growth as well. Our growth hasn't been ⁓ acquisitions. It's been organic.
for the waiver, know, some may, during the pandemic, a major national nonprofit who had an entity in Connecticut, multiple storefronts in Connecticut gave up their waiver business. And we took on around about 20 of those clients.
and we were able to look behind the curtain. was kind of like the odd situation where you look behind and there's a little guy. We were shocked. We were absolutely shocked at the way that the business operation was occurring because they were making losses of between 50 to $60,000 a month, but offsetting those foundational losses from their storefronts. So they were pulling profit from the storefronts to offset the losses that were going on in their day-to-day operational home care business, brain injury business. We fixed that.
and I think we fixed it in less than 90 days and was able to be profitable with those individuals. So as I said we're able to drop into environments and look at those waiver programs and figure out how we can make it work through the model that we've developed.
Miriam Allred (40:36)
Let's talk numbers for a minute. You are obviously in Connecticut and know the Connecticut state market very well. And so I might be putting on the spot with some of these numbers, but I think you have probably a good sense of some of this. You said a moment ago that for ABI specifically, there are 500 spots for ABI. But then you said, I think New York, maybe Massachusetts, they're open-ended. How does that work? How does it go from, a limited population?
Jamie Arber (40:46)
Yeah.
from student.
Miriam Allred (41:03)
to an unlimited population state to state? what are the factors playing into that?
Jamie Arber (41:07)
think the main factors are the state-based budgets, because the federal government will match the state-based budgets. Connecticut are being very fiscally responsible at the moment with guardrails up and everybody's pushing back against that. I think they found $2 billion just down the back of the armchair two days ago, which they didn't know was there. And a lot of providers are kicking and screaming because...
Everybody knows if you're able to pay staff at a decent rate, you get decent staff, you get what you pay for. And that's where a lot of providers are pushing back at this point because home care isn't sexy. So legislators are not pushing for this as we need to get more money into this. New York, think they've realized there's an issue. They're understanding that brain injury
is going to be an expensive level of need for the population and it's a big state, Massachusetts is big state and I think they're being more forward thinking.
everybody talks about the Alzheimer's epidemic that's going to be occurring, the dementia epidemic with the baby boomers. Well, if you have a brain injury, your potential to develop Alzheimer's and dementia goes up exponentially and it occurs far sooner. So the level of lead goes up far sooner.
I know I'm talking a lot about the brain injury piece, but that's kind of where my expertise is in this. When they originally developed the waiver program, the expectation was individuals would transition out of facility settings, acute care settings on high waiver plans. And then they would reduce down over time because they would learn new skills and be able to move forward. That's not the case. What happens is over a period of time, they plateau and then needs go up.
cost of care goes up based on these dementia, Alzheimer's, medication no longer being effective, and behavioral consequences of the injury and what's been lost, et cetera. So the waiver programs become more expensive over a period of time.
Miriam Allred (43:18)
I don't know if you know the answer to this. We're talking again about the ABI waiver and then you also do the ASD waiver. That's two specific waivers. In the state of Connecticut, how many waivers exist? Is it like 50? Is it 500? Just like across the board about ballpark, how many waivers are out there?
Jamie Arber (43:32)
No, didn't.
I believe it's less than 10. There's not a lot of waiver programs because they're expensive. Off the top of my head, you have the ASD waiver, you have the Katie Beckett waiver, again, significant wait lists, PCA waiver, order care, brain injury waiver, and then ASD waiver. And there's also DDS have autism spectrum, but the individuals on the DDS program have, and their budgets are far bigger because they're
The cutoff point is IQ capacity. So if you're 70 or above, you go to the DDS, I mean, DSS waiver, which is the lower budget, we're running about $50,000 a year. If it's below 69, you're going to go to DDS with a far more robust budget.
Miriam Allred (44:22)
Okay. Yeah, that's interesting. That was kind one of the insights that I wanted to understand was there's only 10 in Connecticut. And granted, this is state by state, so every state is different. But I didn't know if there was a handful, 10, or there was a lot of options out there.
Jamie Arber (44:35)
Yeah.
I don't see many states having more than 10 because once you start, you hit the end of the care population, you hit brain injury population, you hit developmental differences, then you're kind of limited at that point. ⁓
know, VA pick up, there are other services right around in Connecticut, the Department of Mental Health and Addiction Services, DMITS, also have specific brain injury waiver slots that they manage because of the dual and try diagnosed clients where you'll have the brain injury and substance abuse and mental health. And note, we service those individuals as well. And that's where those bigger service plans come in because you're dealing with a lot more to keep that individual stable in the community.
Miriam Allred (45:21)
And a minute ago, you said a focus for you guys in 2026, I believe, will be VA because there's overlap with kind of the brain injury population. How do you decide what are the factors that you're considering going towards VA rather than or and or going after more of these waivers in Connecticut? Like, how do you decide where to focus your attention?
Jamie Arber (45:42)
We can develop.
relationships with the referral sources in ways that other agencies are not able to do, be perfectly honest. And we can benefit the population, all of it comes from word of mouth. And I'm confident that once we start providing services, those veterans are going to be talking up our supports. We had a small collection of veterans already within the agency, but they're provided services under the Acquired Brain Injury Waiver Programme, and we've done well by them. So I think that's definitely an opportunity for us to expand into.
working on the ASD waiver, there has to be some fundamental changes to that waiver which I'm attempting to work through our lobbyists and legislative representatives to kind of talk about that and talk those through because it doesn't make sense as it currently stands as a waiver program.
Miriam Allred (46:37)
We've just got a couple more minutes here. Let us look behind the curtain a little bit. think you have talked through the details of these programs and how you guys have flushed this out. I'm assuming the last seven years haven't been all sunshine and rainbows. There's probably been a lot of challenges and headaches and kind of like the messy side of this. For you personally, what have been some of the biggest obstacles that you've had to overcome?
Jamie Arber (47:03)
Probably the biggest source is the challenge that we face when we're developing the clinical side of the business.
Taking on, the Department of Social Services came to us and asked us to take on the ASD waiver to become a provider because a lot of the other providers had stepped away from it. And once you take a look, I can understand why, because the only way you're going to make this waiver work is if you're offering clinical services on this waiver program. So we went out and looked for clinicians and we ended up bringing a clinician in who brought some of their colleagues with them and it just wasn't a good cultural fit. And it was a struggle.
And that was eye opening to me because we've got a good culture within the agency. It's built around hard work and grinding. I mean, that's the reality of it. Our program managers are probably are the hardest working group of individuals I've ever met. Like I was a program manager once upon a time and I get it, but these individuals are tireless in what they do.
they care. That's the biggest thing in terms of when you're having an administrative level all the way down to our staff, we try to make sure they care and these individuals care and you're trying to make sure they don't burn out. So that is the culture of the company. And bringing in individuals with higher level credentials but who have their own agendas to try and change that in order to make their lives easier was a struggle. Because again, you've then got to try and
assist that individual to exit with their colleagues in a way that doesn't cause chaos for everybody. And we were fortunate enough to do that, but we lost a year in that service plan, in that service structure. And plus they take ideas with them that you've developed. that was a struggle for me. But the good thing is with our executive team,
there's different personalities within that the vice president, Kimberly Brisson is amazing. And she's kind of when, when I get annoyed or I'm very much Kevin O'Leary, you're dead to me type of thing. When somebody crosses me, ⁓ she's more like easy going and just, and she, was beneficial having conversations with her because you know, I want to, I want to set the field on fire. And she's like, no, we're just, we're just going to play nicely for a while. I'm okay.
Fair enough. And it kind of took me off the edge of the cliff type of thing. And now we're redeveloping that program. We've got an amazing BCBA in place who gets what we're doing and understands the structure and plays nicely with the other clinicians because our clinical team is super diverse and that's really, really good because there's different ideas and methodologies that come in. Even our management team, everybody's got different skill sets and from different areas. And some of our program managers were directors at other agencies that took a
down to join us and then they've developed within. Some of our program managers were staff members that were standouts that we then trained to step into the role.
And even in terms of retention now, based on these clinic, like certain specific credentials are very, very hard to hire specific clinic clinical credentials. So looking at some of those managers in the long term and seeing, do you want to go back to school? Because we'll cover that as long as you give us a commitment for X number of years, because we know they've got the right mentality. We know they've got the right ideology in terms of what we're trying to do to grow and scale the company in the long run. So that's probably been the biggest challenge.
Miriam Allred (50:32)
Thank you for sharing. That's insightful. Just to hear again, you've had a lot of growth, a lot of success, a lot of like creative ideation, but at the same time, operationally, can get messy and it can be challenging. And just wanted to kind of look at what that's looked like for you. One last question, Jamie, ⁓ from where you sit, what are some of the industry trends or opportunities that you are keeping an eye on in the next kind of like two to five years? what are you?
Jamie Arber (50:34)
Okay.
Yeah.
Miriam Allred (51:01)
subscribing to what are you dialed into? what are you keeping an eye on to kind of stay ahead of where this industry is heading?
Jamie Arber (51:09)
Thank you.
AI is here to stay. So utilizing that to streamline operations as much as possible, because that's a line item expense. you can utilize AI to save funds for three or four positions that you may not need administratively anymore, that will be something. In terms of Connecticut, I can see a lot of home care agencies just not being able to make it work. There's only so many private pay clients floating around. There's only so many waiver clients floating
at
those cost points. So I think there's going to be a break even in terms of there's going to be providers with good reputations that have worked hard to maintain those reputation and.
invested in their agencies that are going to continue to grow and individuals that have been pulling money out of the company not investing it appropriately. I think they're going to really struggle because in Connecticut now as well they have CONI which is kind of an information database system that the state are using and value-based payments are going to be through that. There's also going to be like reputational scores and I think that's going to make a big difference in terms of agencies and families looking at picking
providers. I think that's a good thing because in Connecticut, it's a conflict free state. So the care managers can't specifically refer to us even if the perfect client for us is sitting in front of them. They can't say you need to pick supported living group. So with that, if there's other opportunities for people to look at quality matrix to make their decision, I think that will be a good thing. And I think these smaller agencies that really aren't offering good care, they're just in it
as you said, to make money and then to they'll make their cash and then they'll look to sell. They'll probably be around for a year to two years with that ownership model and then look to try and sell it off. I don't think that business plan is going to be sustainable, not just in Connecticut, I think across the board. I think the companies that are providing good services that are investing in their people and in their infrastructure will continue to thrive. Those individuals that are getting into it to make a quick buck, I think it's not going to work for them.
Miriam Allred (53:22)
Amazing. Thank you for sharing all of that. The last thing that I just want to add to your comment, I think you all are ahead of the curve on this, but I see a lot of larger providers talking about just being a comprehensive, holistic solution. Going away from the traditional in-home care model to how do we programize? How do we come up with opportunities to retain clients longer and become a kind of a one-stop-shop solution for them indefinitely? And I think, again, you all are
Jamie Arber (53:24)
Yeah.
Yeah, that's that's
Miriam Allred (53:51)
The supportive living group is already kind of ahead of the curve on that, but more home care companies are trying to catch up to that and become this comprehensive holistic solution. I think that's really where this industry is heading the next few years.
Jamie Arber (54:02)
Yeah, I would agree with that. think you may see agencies looking at potentially providing more housing opportunities for individuals because the cost of living goes up.
Okay, I can provide a house and reduce down their, their, you know, their spends per month, which they can then reinvest in service provision and the length of the service contract goes up exponentially because they're not going to run out of their savings. So there's fit and I can keep it on one level. So, you know, my 80 year old client is not trying to climb the set of stairs every night, which is increasing her risk of fall. And I think that's going to come in more as well. A lot of, a lot more with AI.
start running percentages and risk factors and elements like that that have never been there before. But what I'm hopeful for is that will not lead to there being a subset of individuals that we would have provided services to that we are no longer providing services to because the risk are too high. That's my only concern with that. Work as comp risks, elements like that.
Miriam Allred (55:07)
Jamie, this has been awesome. This is my selfishly one of my favorite type of episodes where it's like really technical and like in the weeds, but also where we're ending here is like really optimistic. Like there's so many opportunities ahead of us and the demand isn't going anywhere anytime soon. And it's people like you that are innovating, adapting, nimble, figuring out what these clients need, what this industry needs, what this world essentially needs in this day and age. so.
I have really enjoyed this conversation. I've learned loads from you and I think people are gonna get a lot of value out of this conversation as well. What's the best way for people to get in contact with you if you're open to that?
Jamie Arber (55:44)
jarber at slg.com. I'll give you that information so you can share it. And I'm always willing to talk and to help. Apply me with tea and cake and I'll tell anybody anything.
Miriam Allred (55:56)
⁓
Amazing. Thank you so much, Jamie, for joining me in the lab. Another great session. Thank you for being here and thank you everyone for listening.
Jamie Arber (56:06)
Thank you.