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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 (00:02)
Stephen we're here live at HCAOA It is a pleasure to be here in person with you. Welcome
Stephen Tweed (00:14)
This is amazing you have set up here and there's people around and it's just great fun. So much energy at this conference this year.
Miriam Allred (00:21)
Absolutely. You and I have both been coming to this conference for a lot of years and I wanted to shake it up with the stage, the lights, the mics. And I was just asking you, this is not uncomfortable or unfamiliar to you. You worked in radio. I worked in radio.
Stephen Tweed (00:33)
for a number of years and I worked in television at the graduate school and then I worked in film for a while. So yeah, the whole media thing. And it's funny how things come back around in the course of your career.
Miriam Allred (00:45)
I think many people know you, but give us a quick background on your tenure and experience in home care.
Stephen Tweed (00:53)
Well, it goes back way more years than either you or I will admit. But it's been a fabulous venture. ⁓ I first started into home health and hospice when I got a call from my pastor who said I was just elected to the board of directors of the Visiting Nurse Association of Vanango County, Pennsylvania, and they want to do strategic planning.
Will you help me? don't know how to spell strategic planning. And I said, sure. I'm thinking this is a pro bono thing for my pastor. Turns out this was a real organization with real money, amazing CEO. And I led their board through a strategy session. She loved what I did and we connected. And so she introduced me to all the home health people in Pennsylvania and then the state association and then the VNAs of America and then NAHC. so as I say, she sort of dragged me kicking and screaming into home health and hospice.
but home care was just beginning to emerge at that time. And I think you know, I have a son now who's 55 years old, who's physically disabled, lives in a wheelchair and uses the services of home care on a daily basis. So we have a personal connection. We not only know the impact that home care makes on clients, the individual receiving care, but the impact on families. And that may even be bigger. And so what we do really matters. And so that drew us in. And then in 2002, my son and I,
on ⁓ actually Christmas day, his twins were six months old and we were having Christmas together and then he started talking to me about I need to do more work on my computer. How can I, I had this idea and we went to his computer on Christmas day of 2002 and registered the URL for leadinghomecare.com and that became the basis of it. And our intent was to continue down the road of home health, but home care popped up and we were intrigued and that's where
The journey took us. So here we are 23 years later and my work with home care companies is about helping leaders in the top tier of home care grow their business and get ready for the future. And as you know, in 2012, we introduced the mastermind concept to the home care industry. February of 2013 started the first home care mastermind group and that grew into the home care CEO forum, which I ran for
a dozen years and then I sold that business in January of 23 to Jensen Jones, who was a former home care president. Then they sold their business and then he came and did some work with us, started leading some of the masterminds and then said he'd like to acquire the business and so we did that. So that's sort of the journey and I'm still speaking and writing my newsletter every week and doing industry research.
serving on some boards of directors and ⁓ here I am talking with you.
Miriam Allred (03:44)
That was so good, Stephen. And ⁓ you are known as, what do we call you? The godfather of home care, the grandfather of home care, the data god of home care. You are known to be so into the data and the metrics of this industry. And so the question that I want to ask you is about an uncommon but extremely important data point that not enough home care companies are tracking.
or talking about what would you pinpoint as kind of the metric that home care companies need to be tracking and thinking more about?
Stephen Tweed (04:20)
Well, I'll get to that answer in a moment, but let's set it up with the big metric, is hours, hours per week. And that's sort of the currency of home care. And you can assess the size of a home care company by the hours of service that they're providing per week. But the metric we're looking at is hours per client per week. I was looking at somebody's promotion the other day and it talked about how they grew the number of clients.
And I wanted to come back and say that's not a real relevant metric because you could have a thousand clients that are doing an hour a week, or you can have a hundred clients that are doing 40 hours a week. And that's a very different business. So that metric of hours per client per week gives you the basis to dig into other data to really analyze where my clients are coming from, which referral partners give me the
clients with the highest hours per week and the longest length of stay. So now here's another metric that ties into that. Hours per client per week and length of stay gives you the dollar value of the client. And as we talked earlier, correlating with that metric is hours per caregiver per week. And so knowing how many caregivers you have and how many hours a week they're working. And you've probably run into this where owners will say, well, gee, I've got all these caregivers.
but they're only working 20 hours a week, how do I get them to work more hours a week? And the answer is you probably don't because they don't want to work 40 hours a week. And that led us to some other research about the three types of caregiver. So you have full-time professional caregivers who are going to do this work no matter what. It's the questions that they work for your agency or someone else, and they want to work 40, 50, 60 hours a week. So we have to get past that overtime thing. And that's a whole nother conversation.
Then we have the half-time professional caregivers. They're gonna do this work for you or someone else, but they only wanna work 25 hours a week. And then you have the part-time intermittent caregivers who come and go, and the reality is that's the majority of caregivers in the industry. So back to that core metric, where are you getting your new clients?
What do we know about them? What do we know about them demographically? What's their disease state? What's their need for care? And if we're going to consciously grow our business, how do we understand our mix of clients and where they come from? And then how do we refocus our sales and marketing activity to attract referral partners that bring us those clients with high, low, weak, and long-term needs of state? So now we see how that one metric dovetails into other
strategic questions that are answered by data. And if you were in my section yesterday, you saw the metric or the slide that says, ⁓ quote from W. Edwards Deming, who says, without the data, you're just another person with an opinion. And as I said to John Atkinson from AxisCare who was co-presenting with me, I said, we see lots of people in industry have lots of opinions. But when you dig into the facts, you find that often their opinions are wrong. And so being able to
have a basic understanding of the core metrics that you're looking at and where do you start. So again, we come back to that hour per client per week and hours per caregiver week is the basis.
Miriam Allred (07:52)
My first call out is luckily these metrics that you've just identified are easy to track. This is right in the scheduling software. Sometimes we talk about these metrics that there's a calculation involved and it's pretty complex and I that deters people from tracking it. These are super simple, but like you're saying, high impact. And the beauty is, like you mentioned a moment ago, this is what comes to mind is a lot of people are focusing on net new clients. You we always have to be adding new clients, but a different mindset is increasing hours. How are we managing and approaching?
hours, yes, it's good to be bringing on new clients, but focusing on the actual hours per client and increasing that or maximizing that as makes sense. And then on the caregiver side, utilization. I love that you broke down the three different types of caregivers. Hours per week per caregiver. We talk a lot about under utilization. And so you have to be aware of the hours that they're working in order to then proactively manage utilization.
Stephen Tweed (08:32)
That's right. Absolutely.
Miriam Allred (08:52)
What do you think is deterring owners from tracking these two things?
Stephen Tweed (08:57)
⁓
I think there's two parts of that answer. The first one is most people are not numbers junkies like me and a lot of people are afraid of the numbers. ⁓ And so they would like to know the answer but they either don't know how or don't want to do what it takes to get the raw data. 20 years ago I was at our
meeting of our National Speakers Association. My professional association is other professional speakers. And I have a friend and colleague in that group, name of Daniel Burris, who was in Green Bay, Wisconsin. Now lives in Southern California. But Dan is probably the leading technology forecaster in America and the world. A brilliant guy. in our little session there, he was talking about what I now call the four levels of your data stream.
So the first level is raw data. That's bits and bytes of information, which is totally useless because it sits in your computer and until you can get it out and do something with it. So the next level is information. And that's where you tabulate the data to get a report. And so most of the software we're talking about here have reporting mechanisms and standard reports so that you now get tabulated data in the form of information.
But there's way more information than we can use. So we need to convert that to knowledge by analyzing and synthesizing the information to get knowledge. And then as I like to say, we mix knowledge and gray hair and we get wisdom. knowledge plus experience. Well, in order to get the knowledge and wisdom, you got to have the raw data. And so the premise is that every home care company and every owner needs to establish a practice.
that says every time you have a touch point with somebody outside of your agency, it needs to be documented in your software. And so when you get an inquiry from a candidate, when you interview a candidate, when you select a candidate, when you onboard a candidate, when you get them ready for shift, when they work their first shift, when they call off, every touch point gets documented. Every time you
Talk to a client, you get an inquiry call, you do an in-home assessment, you convert it, you start of care, you make a visit, you get a call from the daughter. Every touch point gets documented. Every time you talk to a referral partner, you get an inquiry, you go do a sales call, you send them a handwritten note, you send them a text. Every one of those gets documented. If you do that level of detail and get the data, now you can tabulate that and get information, you can run reports that says,
who are the clients that have the highest hours per week? Or who are the clients that are doing 40 or more hours a week? What's their disease state? Where do they live? What's their geography? Who referred them to us? Did they come from our website? Did they come from a bank trust officer? So when you have that level of information and analyze it, now you have the knowledge that says, if I want to grow my hours per client per week,
I can focus on this group of referral partners that I've already identified, build those relationships, stay in touch, and build a steady flow of clients with high hours per week and long lengths of stay. Now I can go back and look at my database and take my caregivers and put them into those three buckets, full-time professional, half-time professional, intermittent, part-time, and figure out who's working. And what we know is
As I mentioned, my son is 55 years old. He lives in a wheelchair. He uses the services of home care on a daily basis. What Jason taught me is that if the client and the caregiver have a chemistry, if they like each other, they both stay longer. And so we've studied clients, consumers, and what we know about consumers in home care is they want two things. They want reliability, the caregiver who shows up on time every time, as scheduled.
And they want continuity. They want the same caregiver every time. So again, we go back into our information and our knowledge and say, ⁓ we want these clients that have a regular schedule. Now we're going to go and hire these caregivers, half-time or part-time professionals who want a regular schedule. And life gets so much easier inside your company. One of the big challenges we face is scheduler frustration burnout internal.
And it's because they're chasing caregivers and they're chasing clients and they've got this client with three hours of work, two days a week, and you've got this caregiver who calls on. When we establish that stable, steady schedule of clients and a stable, steady schedule of full-time and half-time professional caregivers, now business gets balanced out. Now, that's nice in theory. The practical reality is it's usually different than that.
But with that concept moving forward, we can move in that direction. And we see a reduced frustration on the part of scheduling coordinators. We see less pressure on recruiters. The salespeople can now focus on the referral partners that bring them those ideal clients. And that's how metrics become information, become knowledge that helps you focus your business. as we look at, as you know, at the
Home Care CEO Forum, started the first mastermind group, which became what is today the top 5%. So these are companies in the 95th percentile of revenue. Across the hall from us here is Activated Insights, and they do the annual benchmarking study. So we know that last year, the 95th percentile was about 11 million in change in annual revenue. Our top 5 % group is at 14.
aid or something like that. So these are the biggest companies in the industry and they got there in many cases because they did some of the things that we're just talking about.
Miriam Allred (15:04)
Okay, this is what I want to ask about. First of all, I love that framework, raw data, information, knowledge, wisdom. This is the first time I've heard you say that. Absolutely love that. I think we can both agree a lot of companies are stuck in phase two, which is information. Information overload, analysis paralysis. They are in their systems and they're looking at the reports. They don't know how to break into knowledge and wisdom. What is your advice? How do they break out of...
information into knowledge and then into wisdom. What actionable advice can you give them to break out of that?
Stephen Tweed (15:40)
It starts with curiosity. You got to want to know and understand. And so as you look at your reports, and so you say, okay, I'm going to get a monthly report out of my AxisCare software. And it gives me these points. And I make a distinction between a dashboard and a scorecard. A dashboard is the dashboard of your car. gives you a moment in time. It tells you the speed and the miles per gallon, all of that.
A scorecard looks at data over time in the form of a spreadsheet. And now I can see the trends. Is my hours per week going up or is it going down or is it flat? If my average hours per caregiver per week going up or down or flat. Now I can begin to look further into those reports that I get out of my AxisCare or out of my WellSky system. And then I can compare it to the activated insights industry benchmarking data that says, okay,
Here's my conversion ratio during the inquiry process. We look at how many inquiries did I get? What percentage of them did I convert to an in-home assessment? And then what percentage did I actually close the sale and begin the start of care? And that data is available at Activated Insights. And we have it for the industry. We have it for the leaders, which is 2.8 million or above. We have it for the...
Miriam Allred (17:05)
Masters. ⁓
Stephen Tweed (17:07)
I hate when I draw a blank. That's okay. Masters
at 5 million are up. Now you can look, and of course we have that data for the top 5 % group, which is 10 million and up. Now we can look at where am I now and what are the bigger growing, more profitable companies doing? What do I need to learn to know to move from where I am to where I want to be? And so it starts with the curiosity.
It starts with the understanding of these metrics and the data that you're gathering. It's understanding your home care operating system, your software and where you can go for that. And I've done a fair amount of work with my mastermind groups, with both WellSky and AxisCare to look at their standard reports and reports that they can get and to be able to say to the software companies, what would it take to get
this bit of information more readily. So for example, a couple of years ago, some of our Mastermind members that were WellSky users were talking about it and ⁓ said, we need different information. And so I knew the folks at this was when it was still ClearCare before WellSky. And so I called them up and said, hey, I have a group of members that are interested in information and knowledge.
And so we put a little focus group together of our members and they identified what I call, if you could wave your magic wand and have the data, what would it look like? And we created a CEO dashboard. And then we sat down with the ClearCare folks and said, here's what we want. And they said, we can do that. And they built a button called CEO scorecard or dashboard. And that information was readily available. So the technology will do it. You just have to know.
what you want in what format. And so the CEOs got these, I think there were 12 or 17 metrics that could pop up at the spur of the moment, or they could get a monthly report with those metrics to show them their information over time.
Miriam Allred (19:20)
And
you and I spend a lot of time with this kind of like top 5 % group. The things that I observe is consistency and simplicity. Again, I think it's easy for owners to consume, the benchmarking report and get overwhelmed. I need to track everything. But I think, know, dial it back, keep it really tight. We talk about scorecards and dashboards. Keep it really tight and really customized to your business and be consistent about it. But then also keep an open mind and be adaptable.
Times change, metrics change, we learn something new. so ⁓ I was talking recently with someone about like set it and forget it managers, you know, that kind of put that scorecard in place and then it's in place and it's, you know, dusty in a couple of years. think consistency, but also adaptability and being willing to mold your metrics as your business evolves.
Stephen Tweed (20:05)
Well, you're exactly right. And it goes back to curiosity. What do I want to know? What do I need to know to make those strategic decisions? And as the industry changes, as the data reporting mechanisms change, I have access to a new look at those numbers. it's not about managing by the numbers. This is a people business. This is a human interaction business. So it's not about
making business decisions only about the numbers. But the numbers and the technology, and yesterday we were talking about AI and what it will do, it's not about replacing the people or the interpersonal human touch, but it's freeing up the capacity so that caregivers and care coordinators have more capacity to interact with clients and family caregivers and make a more meaningful impact on their lives. And so we
We keep the numbers in mind, but primarily for the purpose of being more human in our relationship with our clients and their families and our referral partners.
Miriam Allred (21:13)
And technology is definitely a driving factor in this conversation. Technology is as good as it's ever been in home care and it's only getting better, which means we have access to more data and more information. And that's where maybe people get caught in that information bucket is because there's just too much information and they don't know how to sort through it. And they can't break into the curiosity because there's just too much and they don't know where to start, that's where, yeah, simplification, break it down, keep it really tight, really simple. Don't get overwhelmed with all the information.
Really keep it simple.
Stephen Tweed (21:44)
And one of the things that we did a number of years ago is identified what I call the five phases of flow. a client goes through, in working with a home care company, goes through those five phases of flow. So the first phase is the attraction phase. That's making the phone ring and that's sales, marketing, social media, community outreach. The second phase is the conversion phase. That's converting callers to clients. So that's taking the inquiry call, doing the in-home assessments.
closing the sale, doing the start of care. Then we have the staffing phase and that's recruiting, selection, onboarding, training, retention, ⁓ that leads then to having that bucket of caregivers and knowing do we have full-time, half-time, part-time, that leads into the fourth phase, which is the caregiving phase. And that's the day-to-day operation, that's scheduling, that's care coordination, that's on-call evening and weekends, that's all the stuff that we do.
in the day-to-day operation of the business. And then the fifth phase is the collections phase. It's billing, it's collections, it's keeping the cash flowing. And so if an owner operator thinks about it in the context of those five phases, now we can look at metrics. And so instead of having 27 metrics for the business, we have five or six metrics for the sales and marketing function, five or six metrics for the conversion function.
For the recruiting and retention function, we use a funnel and we put high quality caregivers in the top of the funnel. We filter them out with our selection process and we have a steady flow, high quality ⁓ new hires coming out the bottom of the funnel. And so we have a series of metrics for the funnel that ultimately result in how many new hires are still here after 90 days and how many new hires are still here at the end of a year.
And from Homecare Pulse Activated Insights, we know that the turnover last year was 75 and was down a little from 79.2 the year before. And so we know that of that turnover, 57 % happens in the first 90 days. And now we can focus in on what can we do to improve retention in the first 90 days. So we're seeing how all of these, there's all this data and all this information.
But if we focus down on each of the phases and figure out what do we need to know to make better decisions, and then how do we become wise owners by putting this information and knowledge together with our experience. And that's where we found that in the home care mastermind groups, you have 10 people sitting around the table or 20 people, 10 companies.
that are doing 10 to $50 million in annual revenue, there's just a wealth of experience in that room. So we take the information and knowledge and we learn from OPE, other people's experience, how we then grow that and become wise decision makers. So ⁓ it all comes together. So I love what you're doing here because it starts with that one number, hours per client per week, and it dovetails into a whole.
body of knowledge, but as you said, how do we keep it simple and meaningful so that the owner and the C-suite team at the company can wrestle with the information and analyze it and develop knowledge and then with their collective experience, make wise strategic business decisions.
Miriam Allred (25:16)
Stephen, let's talk about where this industry is headed. Nobody has a crystal ball, but if anyone had it, I think it would be you.
Stephen Tweed (25:23)
Yesterday
my crystal ball is broken. has a crack. The picture is fuzzy, but I'm getting there.
Miriam Allred (25:29)
You're getting there. What are you keeping an eye on? What are you seeing that's coming? What are you looking at, observing, thinking, you know, kind of this could be where the industry's headed? What are some of the trends?
Stephen Tweed (25:45)
Well, and this is very timely question because we just kicked off the 2026 Future of Home Care study in collaboration with AxisCare. This is the third year of the study. So now we have three years of trend data. And so we start with pain points. What are the major pain points that are getting in the way? And this year and last year and the year before they were the same caregiver shortages, caregiver recruiting, caregiver retention, new client attraction. And so we say, okay, what does that mean?
for the future. Then we look at systems. One of the things we've learned from the top 5 % mastermind group is that leaders in the industry are systems thinkers. They think in the context of if there's a task that we do more than once a week, we need to think about systematizing. The tasks that we do every day are about systems. And so from those five phases of flow that we talked about, we have identified 12 specific systems.
And a system is process plus people. it's step-by-step process and the people with the knowledge and the skills and the willingness to follow the process. And so we have a sales process, a marketing process, a conversion process, a recruiting process. And so then we begin to look at where that's going. And then we looked at technology. And the first year we asked about technology trends and AI was on the top of the list. Second year,
technology trends, AI is still on the top of the So we've gone out and done some side research into AI and there's been a lot of conversation that here the last two days about that. And so in our current study, we have a whole section on how do you see ⁓ AI impacting technology and impacting the business. And from my research, I've learned that there are really three levels of applying AI. One is the task.
And so there's lots of tools to make us more effective and more efficient to task quicker. The second level is the internal systems. So we look at those 12 systems and how does AI make those systems more effective. But the third level is the competitive ecosystem. How do we differentiate between home care companies? And there are 29,000 companies in this business. The median size last year was 2,003,000. And so how do you differentiate from the other
14,500 companies that are lower than 2.3 in revenue. ⁓ And that's where we look at where the technology is going. So that's a long answer to a short question. But as we look down the road, we see caregiver shortage will be a driving pain point. Systems development will be a driving process. Technology and AI.
will help us make systems more effective and free up the people to do what the people need to do. The demographics are very clear. This industry is not going away. We saw Jason Dorsey on the first day of this conference talking about generations and the fastest growing generation are the over age 65 people. And the data from AARP are very clear that they want care at home. So when you put it all together, the future
is very positive. very optimistic. I'm very excited about where the industry is going. We're going to see a consolidation from 29,000 little tiny companies to a growing number of bigger companies, more sophisticated using data, using technology, developing leaders at different levels. So leadership, yesterday, as we concluded with one of our predictions, John Atkinson talked about the companies that have great leaders.
who develop great leaders to grow their people are going to be ahead. So it's not just about facts and data, but it's about leadership and teamwork and creating culture that really are going to lead to creating a great industry. And as we have seen in other industries, when they're highly fragmented like home care, they begin to consolidate and come together and develop new systems, new technology, new leadership.
So it's very exciting. And you're right on the cutting edge of all this is the strategy labs.
Miriam Allred (30:05)
We are together on the cutting edge. We're seeing all of this unfold right before our eyes. Stephen, you are fantastic. That was fire. I feel like I don't need to say anything more because you just like mic drop and you are, you gave like so many formulas. You know me, I love in my mind, I'm literally writing down all of those formulas that you just said. It's so actionable. People can literally take everything that you just said, take it back to their business, write it out, apply it to their business. That was so well said. So thank you so much for joining me live.
On stage at the HCAOA. you. Stephen Tweed, everybody. That was fantastic.
Stephen Tweed (30:35)
Thank for having me.
you