Subscribe
Share
Share
Embed
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 (00:10)
Welcome to the Home Care Strategy Lab. I'm your host, Miriam Allred. It's great to be back with everyone this week. Today in the lab, I'm joined by Neal Kursban the CEO of Family & Nursing Care in Maryland. Neal, welcome to the show.
Neal Kursban (00:25)
Thank you, I'm looking forward to being here today.
Miriam Allred (00:28)
It's been a while since I've interviewed you formally, but I have followed your journey and I think it was at HCA away this past fall that someone said, why haven't you had Neal on the show? Maybe it was your brother or cousin or someone in the business, but people have told me to interview you again. So better late than never. Here we are.
Neal Kursban (00:48)
Yes, I'm happy to be here.
Miriam Allred (00:50)
Awesome.
Well, let's start with your origin story. Tell everyone about family and nursing care and your kind of the founder story. And then when you joined the family business and then give us some details on kind of the profile size, shape, payers, geography of the business. So we can have that context going into the conversation.
Neal Kursban (01:10)
All right, sounds great. So Sandi Kursban, she's my mother, she founded the company in 1968. And what's neat is there wasn't really much of an industry. So often she's referred to as a pioneer in home care because back in the day people would stay in the hospital for weeks or months even before going home and didn't really have a need as much for home care back as much. So 1968, she founded it and her
Her goal was, I want to service our elderly population, charging them as little as possible, and I want the workers...
the caregivers we call them today, of course, to earn as much as possible. So her advisor back then, and I've asked her many times, was it your accountant or was your lawyer? And she doesn't remember, but her advisor said, well, good luck. Good luck staying in business. And back then, by the way, it was very uncommon for a woman to own a company. And I got some funny stories I could share about that. anyhow, and so they said good luck. And what the recommendation was by the
advisor was to have the workers be called, what they called it, contractors. Sandy, my mother, said, well, what's that? They said, don't worry about it.
So little did I know, or we know decades, 57 years ago that the term independent contractor is prevalent in today's, here we are today. And so part of our business is run with the term often is called a nurse registry. And then we also, in my years, added the employee, the agency model, later. So that's part of the Sandi story.
And then I joined the company in 1995. It was late 1995, so I'll be hitting my 30 year anniversary later this year. Just remarkable to think of it. This is what I'm doing for 30 years. And so, you know, my...
My journey was the first several years, again, I was in my 20s and I wasn't quite as mature as I am today. So I'm not sure if I was ready to be in management position. So it turned out to be very fortunate that I had the benefit of having done all the positions in the company. And so my title for many years was basically office floater, informally. And I remember I had the desk that I wasn't even in there that much because I would come into the office and if someone
was sick or on vacation or...
attorney leave or whatever it may be, my job was their job. And if everyone was there, I had projects stacked on my desk of things to do. I was a coordinator and I interviewed caregivers and I did orientations and I did accounting and interviewed office employee, HR, basically every aspect of the company for many, many years. Did on call, which was lots of fun. So having the benefit of having
lived it and then grown to where we are today, it's a neat story.
Miriam Allred (04:08)
Let me make sure I've got a couple things right. When you joined it was 100 % registry model and you helped introduce kind of the home care side, correct?
Neal Kursban (04:15)
Yes.
That is correct. Yeah.
Miriam Allred (04:21)
And the
business was how big, how many clients, what's revenue size were you when you joined in the 90s?
Neal Kursban (04:29)
I mean it was a lot smaller. So I was employee, office employee number 12 or 13, and today we have about 100. So we've grown substantially since those days. I mean granted, the rates were lower, so the revenue was much lower, and of course with inflation rates are higher. So it's probably like four or five million in revenue then, and now we're up closer to 65 million a year in revenue.
Miriam Allred (04:55)
And what about payers? What was the payer mix and what does the payer mix look like today?
Neal Kursban (05:02)
So the payer mix was people that would pay privately. So not Medicaid, not Medicare, not family Medicaid, not basically out of their own pocketbook, their own checkbook, and would pay for the service.
and even when I came and joined and things have not changed so even the agency employee model that I introduced later in my time also kept that same very narrow lane of private pay so it's just private pay.
Miriam Allred (05:32)
Okay, even to today. also make sure I have this right, today the registry home care split is about 50-50, is that right?
Neal Kursban (05:40)
It is. So again, it had a...
Well, see 2007. So it's been 18 years of us running the agency. And I guess the other close to 40 years plus the last 18 years of running the registry. So yes, the agency has definitely caught up. The model has caught up and there's we could have a whole other session on the pros and cons of both and having run both and live both and still today living both models. There's certainly pros and cons. But but yet as we as I sit here and speak to you today in 2025,
They are now about equal size.
Miriam Allred (06:14)
And we're not going to go too far down this path, but in short, like what is your philosophy around that? Today it's 50-50 split. In, Neal's ideal world, would you like it to be all home care, all registry, keep the mix? Like in short, what does ideal look like for the business?
Neal Kursban (06:30)
Great question. ⁓
I don't have a vision on that. I'm very much what does the client family, what does the customer want?
And we find that some customers, and we're very open about here's the two models and which is your preference. So we get into, without confusing them too much, we do explain that we have two models. But, and at the end of the day, the register, mean, for simplicity purposes, I would just to keep it simple, it's about $5 less per hour if you're a client that gets care on the registry side. And the caregivers actually make more money per hour, but there's other things that they're not getting. But their hourly amount tends to
be a little bit higher than what the employees make on their agency side. wait a minute, does that answer your question? Yes.
Miriam Allred (07:19)
Yeah, so it's all about the clients. You don't feel
strongly about it being more home care heavy or more registry heavy. It's what your market needs and you're able to deliver.
Neal Kursban (07:28)
Right, it's what they, yes. And that also holds on the caregiver side as well. some caregivers prefer the independent contractor status and others prefer an employee status. And again, I don't have a dog in the fight. It's just whatever the client and caregiver feel is best for them.
Miriam Allred (07:48)
Well, we're not going to go too far down this registry side, even though we could, because I think that's really interesting. Today, what I want us to focus on are really like your three differentiators. Like you mentioned, your mom, Sandy is a pioneer in home care. Not very many home care companies can say they've been doing this for 50 plus years, but you were one of the few that can. And so there's kind of three differentiators that you've helped me identify that you believe set Family & Nursing Care apart. The first being
service obsession, the white glove experience that you're delivering to these clients. The second is caregiver sustainability. We're going to talk about how you're paying these caregivers so much and some of the foundations and programs that you've built to keep caregivers for years and years and years. And then the last thing we're going to talk about is being a family owned and operated business for this long. You've been approached by PE, you've got a lot of outside interest and money coming your way, but you've decided to keep the business.
independently owned and operated. And so we're going to talk about that as a differentiator as well. So just wanted to kind of preview the three areas we're going to talk about. Let's start with the service obsession. You explained to me that you want your business to deliver an experience compared to maybe like the Ritz Carlton, you know, like the top tier experience that these clients can have in home care. And so the question I want to ask,
Neal Kursban (09:03)
Right.
Miriam Allred (09:06)
Every home care business says that I offer premium care, quality care, like we're the best in our market, but you truly have built that. And I want to know what does that look like in practice? How are you and the team delivering that experience over and over and over?
Neal Kursban (09:23)
Okay, it's a loaded set of questions you asked, I'll often say we are in, we're not in the home care business, we're in the service business. Because again, private pay, family's clients paying 35, $40 an hour, whatever the going rate is in their respective market. And if you do the math very quickly, mean just.
30, let's keep the numbers simple, $40 an hour, four hours a day. Four times, it's $160, times that by five or seven days. The math adds up very quickly. It's not like when you get your cable bill or your phone bill and it's 100, 200, whatever. I mean, this is a lot of money. And if people are willing and able to spend this kind of money, I myself would expect.
that in return. I would expect to have a service experience that's gonna wow me. And so that's our job at Family & Nursing Care So that's a little bit buzzwordy, so we'll get into the specifics, but it's a philosophy. Well, actually I do gotta go a step further, and this is a bit into the weeds, but so every week we have an all-hands huddle meeting with all 100 of our employees. It's 15 minutes.
and every week we go through one of our guiding values. have 15 guiding, we have a mission and then 15 guiding values. And we go through each and every one of them, I'm sorry, we go through one of them that week and then we give an example, an employee will give an example of how they lived it that particular week.
And so it's just a constant reminder. of times, and we used to have this on the wall, and there's our guiding values, and this is what we all are supposed to know, but we live it every week, and we remind people, then 16, the mission plus 15 guiding values every 16 weeks, we start all over again. So anyhow, it's constant. It's just constantly dripping in who we are, how we are, how we do, what we do, when we do, what we do.
Miriam Allred (11:21)
Yeah, explain the team structure, assessments, on-call. What does that experience for the client look like?
Neal Kursban (11:29)
So we are a company that is begging for client feedback. So in my view, the only way you can improve is to know where you're falling short. so years ago, was anecdotally we thought we had a good idea, but this goes back at least 10 years. We found a survey company that is really able to get specific with the questions on all parts of the operations of our company.
from the time they call, or each time they call, how long did the phone ring? How many seconds? We literally have, between that, how long did it take to transfer your call? So every aspect of, from the initial intake to the time's already a client and their accessibility to get ahold of somebody, to get ahold of somebody live, because we have a very strong philosophy that people don't want to call and have to leave a voicemail. And so what's our infrastructure built in a way to prevent that from happening, even if it's not,
primary person I used to speak into, but how do they get... So we have this company that really identifies where we're strong and where we're... I'm sorry. Our clients tell us where we're strong and where we're not. And so, for example, the last couple years, we've seen our score not be as high as we'd like, and it's benchmarked across the industry. And it's not as high as we'd like on the nights and weekends, or on call, what people call on call.
And so, we've seen this now for a couple years. We've tried this internally, we've tried that internally. We haven't quite cracked, we hadn't quite cracked the code. And only through a lot of trial and error and consistent feedback that what we were doing still wasn't making a noticeable difference. So it kind of brought us back to the drawing board. What do we gotta do now? What do we gotta do now? It's not what do we think how they're reacting, it's what are they telling us? it's, and our operation plan,
really is based on what our clients are telling us.
Miriam Allred (13:20)
Is this survey
company what you can name names? this a company we've heard of or is this something local to Maryland?
Neal Kursban (13:25)
It's not one
that, I think there's one that's commonly used in this industry, but we don't use that. I mean, it's called NBRI. They're in Texas, N as in Neal, B as in Barbara, R as in Richard, I as in Igloo, NBRI.
Miriam Allred (13:35)
Okay.
Neal Kursban (13:38)
And so yeah, they do benchmarking for, and it's really worked for us because again, you can cater your particular questions that you think are important to your company and they do have, you know, they can benchmark that against others in the industry. So it's been great. It's been really helpful.
Miriam Allred (13:51)
And you mentioned
managing just the call volume, a business of your size, there's a lot of call volume. Do you have a dedicated team that just answers the phone? How big is that team? How is that structured? How do you manage just the pure call volume?
Neal Kursban (13:58)
Yes.
we do that to the clients. We also do this with the caregivers. We ask the caregivers for constant feedback, and they are not shy, thank goodness, about, and they can choose to go anonymous, or they can put their name, and most of them actually put their name behind it, and I like that. And the client's the same thing, you can do it anonymously at house. And also the staff, we do it, I do it for my office staff. I want to know how do you feel about where we can improve, and what are we doing, what's working, why are you still here?
Why do we have such low turnover? anyway, feedback, feedback, feedback. Go into your question. So if you were to walk into our office, you would see three people whose full-time job is to say, Family & Nursing Care how may I help you? Because the volume is so high that they're just constantly, like the volume. And there's some admin responsibilities they have and things along those lines. yeah, it's all day every day there's three people saying, hi, how can I help you?
Miriam Allred (14:59)
And let's talk about another key component is the like the clinical side of things, sending a nurse out to do the assessment, to do the reassessment, the care planning. What does your process look like there? Do you have how many nurses on staff? Is there any kind of like secret sauce to your, your approach when it comes to the assessment and the care planning that maybe is an elevated level?
Neal Kursban (15:23)
Well, just to be clear, the assessment only takes place on the agency employee side. Just there's legalities behind my answer in there. So half of our business, yes, has registered nurses. And I know not all states across the country require to have an RN to do an initial assessment or plan of care. In Maryland, yes. In DC, yes. Other states, yes. Others, no. So OK. So it's.
We're not set up where the person that goes out, this is probably a little different than most, but we don't have someone get into the dining room to then get the case to go active. We do all that, we do the majority of that. I'd say 90 plus percent of that is done prior to anybody going into the house, whether it's our nurse or a caregiver. We handle all the intake activity over the phone.
The nurses are not there to close the case to get it to go active. But the key with, there's an expression, guess, you can kiss a lot of frogs before you find the prince. I would say in our world, we've had to kiss a lot of nurses to find the nurses that we have today.
Let's just say the nurses we have today are philosophically aligned with getting to yes. They recognize that the most important thing and the reason why we're in business is for that older adult to have a caregiver in their house. And I know it might sound strange I'm saying this, but some of the previous nurses sometimes would make that more complicated than what it needed to be.
Miriam Allred (16:40)
Okay, this is pretty interesting that maybe 80 to 90 percent of the intake assessment getting a case started actually happens over the phone and virtually rather than in the home. More than 90 percent. Okay, this is
Neal Kursban (16:52)
No, more than 90%. Closer to
100, to be honest, like at least probably closer to 95.
Miriam Allred (16:59)
And there's kind of two components here, like the office staff and their preference, and then also the client. If they don't feel the need to have someone come out in person and see them and assess the home and do that, it sounds like that's kind of just your methodology for doing things. And it seems to be working well.
Neal Kursban (17:15)
Well, I would love to say it was genius, but again, on the registry model there's constraints. And so being born and that's how the company was founded, that's all it was allowed to do. But then it seemed to work also on the agency side. it's the kind of people that do our initial intakes are.
I don't know the other word. It's just that this is the way that they're set up to be trained to make sure You spend whether it's 20 minutes or an hour and 20 minutes or 45 like whatever it is that's needed To give that caller the experience. That's gonna be like wow I don't it doesn't matter if someone comes to my home or not or I don't even need to call another company you guys I can feel the warmth I can feel that I'm gonna be taken care of and
and then, by the way, a nurse is gonna come and do an assessment is almost sort of the message.
Miriam Allred (18:10)
Hmm.
And pretty interesting. you have about a hundred office employees. Most of them are working fully remote, you know, post pandemic, they didn't really come back to the office though. They're fully remote. So I'm assuming all of these nurses that you're referring to, they don't spend a lot of time in the office. They're out in their homes and conducting all of these phone calls, these intakes remotely.
Neal Kursban (18:30)
Yes,
I mean, although part of the service obsession is making sure people are technologically capable to do their job as efficiently as possible. So I've had to hundreds of thousands, actually I'm go higher than, well millions may be an exaggeration, but somewhere between hundreds of thousands and millions of dollars on giving people the tools they need to be successful where they are.
whether it's in their home having two or three monitors, whether they're having a portable printer, just the technology, the phones. We pay a tremendous amount of money to give people the tools they need to be as efficiently as they need to be where they need to be.
Miriam Allred (19:05)
can you be a little bit more specific there like monitors, phones, any other like technology products that you have found? that have been particularly helpful with having this huge remote office staff.
Neal Kursban (19:19)
right now and there is not a phone on my desk. And if you go to every single desk in this office, there's not a phone. So we actually don't have a traditional phone. So everything is done, in our company, everything is done through Teams. So Teams answers our calls. Teams is how we communicate internally. Some people use Slack. So that is our phone system and it's also an internal way of communicating.
Miriam Allred (19:41)
Okay. Which is the Microsoft suite. If anyone doesn't know that Microsoft teams and it sounds like it's internal and external. So it's all baked in one. You're not using a separate external system.
Neal Kursban (19:51)
We're making an outgoing call. on Teams. that what? Yes. I think that's what you're asking.
Miriam Allred (19:54)
Yeah.
Yeah. Like it's one thing to like use it as like a messaging tool internally, but it's another thing to use it for like outbound calls or incoming calls from prospective clients. Okay. Which is nice to have it all centralized in one system. That's probably the beauty of it. what about you talking about like surveying these clients ongoing? What's the cadence?
Neal Kursban (20:03)
Right. Use it for both.
Miriam Allred (20:18)
for reaching out to these clients? How often are you reaching out to a single client?
Neal Kursban (20:22)
So again, it doesn't come from us, it comes from this NBRI the third party company. It's done via email and it's a month after care starts.
and then it's annual from the month of when they originally started. So if they're with us for three years, then every year on the month that they started. So we get a, we call it the new client survey feedback, and then we have the annual or ongoing client feedback. And then where there's ways to...
parse the information where you can compare and contrast and you can merge them together and take them apart. You're geographically. So it's really, their software is quite sophisticated also. So it's been really helpful to isolate, well, this particular area of this zip code is what's going on over there. And then it's really helpful for us to know where we're performing incredibly well or if we're...
for under performing.
Miriam Allred (21:16)
And it's sent to the client via email and they respond via email as well.
Neal Kursban (21:21)
It's sent to the primary contact of the family. So whether it's the client themselves, their spouse, their adult child, or whoever. So it's sent to them via email and they are responding.
And so I think it's sent like every two or three days and I think after a third or fourth time. our response rate is, it's still actually over 20%, which apparently is pretty decent. I wish it was higher, but they say it's statistically relevant to give you the data that you need to make business decisions basically.
Miriam Allred (21:54)
Okay, so apart from the survey, obviously the caregiver is out there visiting the client, like that's the primary FaceTime. Apart from the survey and apart from the caregiver, are there any other unique touch points from the office, from the nurse, from any other parties, to the client other than the caregiver and these surveys?
Neal Kursban (22:17)
Well, in addition, we have registered nurses and have client service managers, and we have people that do intake that will own a smaller percentage of time. So, okay, there could be several different people that are visiting a client home, but the most common is either the registered nurses on our agency side and or our client service managers. every day there's...
Like every day a client service manager is doing multiple visits. And again, we have a lot of them, but so then we have client service manager associates who handle their caseload while that person's spending Tuesdays visiting, eight, 10, 12 clients. But it's more of a retention tool than anything else. It's really just getting to know the client and the family better and also helps.
you there's that tricky little step when you get into their door and just being in the house, I mean, all the benefits of, you know, the parking was a little tricky and you got to go to the back and park. So there's just different things, the benefits that come from going to the house. So yes, the nurses, the client service managers, sometimes our business development sales, marketer type people will go and other times the person who does the intake, actually the 5 % will actually go and go to the house because the family demands it. And again, that's what the
Miriam Allred (23:27)
Mm-hmm.
Neal Kursban (23:28)
customer wants. In addition to the hour we spent on the phone, you know, if makes you comfortable, I'm happy to go to your dining room. We can talk about the rest of
Miriam Allred (23:36)
The reason I ask about just other touch points is back to the kind of Ritz-Carlton analogy. It's like you think of like white glove experiences. There's a lot of touch points, like almost to the point where it's excessive. when you're checking into a hotel, it's like there's texts and there's emails and there's more texts and there's a phone call to the confirmed parking. And there's just like so many touch points. And so that's why I'm like drilling in a little bit here of like, how many touch points do you have?
But also the thing that we're about to talk about is like the caregiver. Like the caregiver is like the point person that knows them so well, that shows up at their house every day, that like is also giving them that white glove level of care. And so I'm not fishing that there needs to be or implying that there needs to be more touch points. I was just curious of like the other touch points that exist.
Neal Kursban (24:22)
Let me speak to that
because I'm also the adult son-in-law of my father-in-law who's getting care. And so it's been interesting from Family & Nursing Care on the agency side. So it's been interesting because I remember initially the overwhelmed feeling that a family often goes through if they're starting care with urgency. It's one thing if you're thinking about it and let's get some help and whether you start this week or that week, it doesn't really matter. Those are, I'll say easy.
you know, least 50 % or more of our clients need care within a day or two of when they call. And they're going through a lot. And they don't even know between the hospital discharge plan or the rehab discharge plan or the maybe the Medicare home health agency that's gonna be sending in a nurse and then we're gonna be sending an aide. I mean, they're drinking water from a fire hose and often haven't even had home care before. So we are very strategic about the timing of our touch points to the family.
email, calling, texting, like we have a lot.
of internal discussions and there's not, you can't even develop an SOP because each one is so, I mean you get themes but there's a way to not overwhelm people but you also have to get communication across and you know that they're often feeling overwhelmed. So, and I lived it myself so I can certainly relate. So I just, so the whole new case or new client experience, I think that, and that often is gonna, when we get to the caregiver of course, the caregiver that goes in is gonna ultimately
make or break this long term success, but a lot of companies kind of screw up even before the caregiver shows up. And that's not good. That's not good.
Miriam Allred (26:03)
And you even
mentioned a few minutes ago that you burned through a lot of employees that weren't the right fit to handle those intake calls. Like there's a certain person that needs to be in that seat that can do this extraordinarily well over the phone. And it sounds like you have over 30 years worked through a lot of people. And now you've maybe found those kinds of diamonds in the rough that are really good at that process.
Neal Kursban (26:25)
And again, yes, and we are fortunate that we have very low turnover at this company. mean, the last two years we had 3 and 4 percent turnover in our office.
Yes, that's good. I mean, it's good. Obviously, people wouldn't stay if they were unhappy. But it's also, you learn, you understand, you go deeper. Every employee, have institutional knowledge. The longer people at your company, assuming they're not resistant to change, and we can talk about that in a moment.
they have to be willing to change also but assuming they're also willing to change and go with whatever the new way of doing things is people are very committed and they're very passionate
And I'm sure everyone says, oh, you wouldn't believe my Susie's, she's compassionate, or very passionate also, but it's hard to get a high percentage of the 100 people, I would say a very high percentage of our staff is very, very engaged. And I it might sound nice for me as a CEO to say that, but it's reflected in what the clients are telling us, what the caregivers are telling us.
whatever referral partners are telling us and what they're telling us, what they tell me, what they do when they put in a survey and they're very willing to speak out about that. I want to touch back on one thing you mentioned before and it's actually really important part of our ability to work remotely is we do have recorded lines. And so we have the ability to listen in.
and use its company say for training and quality purposes. And what we had for a period of time but it wasn't working consistently is the AI would tell us when the word frustrated or amazed or rate or cost or expensive, whatever the words that you want to manage, it could say on this 18 minute conversation go to minute 10.
ten minutes, thirteen seconds and then you can hear what so it would tell us where to go to save our managers time of having to go. Unfortunately we've had some R &D issues and so we've had to temporarily take that off but we still have the lines that are recorded and so when you have he said, she said conversations you can pull it up and listen and hear what was said and what wasn't said and use it either for an example of what to do well or what can be a training opportunity.
Miriam Allred (28:40)
I'm glad you brought that up. And we've all been on the receiving end of hearing that line. This is being recorded for training purposes. how often is someone actually reviewing those calls?
Neal Kursban (28:50)
that was my skepticism. like, come on, people are have time to do this. the reality is, it's baked into every director's, for lack of a word, their job description. And it's important, especially if people are remote, it's hard to know, like...
It's hard to know what you don't know and then also you can, I would say more often though it's used literally for examples of when newer people are hired or even existing employees and it's like, look, here's how the delicacy of this conversation was handled. So it's not intended to be a reprimanding tool, but it is really helpful to help make us that much better.
Miriam Allred (29:26)
Mm.
Absolutely. I myself have used software like that. You are a company of size and have some dollars behind you. There's a company called Gong. That's a tech platform that you should look into that does exceptionally well at this because you're right. A single call and then a thousand calls. Like there's so much rich information in there, but it's so hard to prioritize sifting through hundreds and thousands of calls. But if there's, know, really smart technology that can pinpoint all the keywords that can bookmark and highlight things and
Neal Kursban (29:49)
Yeah.
called G-O-N-G.
Miriam Allred (29:57)
the trends. G-O-N-G. Yep. I would recommend looking into it as a...
Neal Kursban (29:58)
Okay, no thank you. That's, do you know what the interface is with Teams? Well anyway, we can talk about that afterwards. All right, all right.
Miriam Allred (30:05)
That's a good question. I'll let you know, could sidebar on that after.
Um, but I, I agree just capturing that information and then using it for training purposes and having the directors review that, like, there's just a lot of value in that. And again, comes back to this like white glove experience, like that information matters. Every call matters. And in order to improve over time, you have to know what's taking place in those conversations.
Neal Kursban (30:28)
I
know it's not intending to be the style of leadership at this company is really lead with a carrot, not with a stick. So it's not looking for gotcha moments. It really is looking either for an opportunity of where or how it could have been improved, either slightly improved or massively improved. But usually it's just even tweaking what was shared and how it was shared.
But usually, anyway, I've already said this, it's exemplifying what we do well and then using that to kind of be the case study.
Miriam Allred (30:56)
Exactly.
Finding all of the good things, you know, likely there's so many good things, so many good phrases, so many good, so much good dialogue, and you can extract that and use that in your marketing efforts as well. It's not all reprimand. It's not all what you could do better, but more so here's what's going really well. And here's how we can use that to our advantage. Let's transition into talking about your caregivers. At the start, you mentioned that even Sandy's early philosophy was charged as little as possible, but
the caregivers as much as possible. Are you currently paying maybe the highest in your market or where do you compare just on that pay scale?
Neal Kursban (31:35)
As far as I know, the average wage that we're paying, which is close to $22 an hour on the agency side, and it's 24 and change on the registry side. That's what it averages. The market's typically in the mid-19s or 20s.
So it is a choice to pay the caregivers more money. It's a philosophical view on my part. Just think it'd be hard to live on $18 or $19 or $20 an hour, and even think it's hard to live on $22 or $24, but it makes it a little bit easier. So I want to do that.
Miriam Allred (32:08)
And when it comes to margins, What is a healthy margin for you on the home care side and on the registry side? And are you always achieving that or are you paying a lot of overtime? So margins aren't as a bigger priority. Like talk to me about your thoughts on margins.
Neal Kursban (32:23)
Yeah,
and just to be clear, there's different margins. There's what's the rate to the client and what are you paying the caregiver? That's one margin. Then there's the rate you're charging the clients minus the caregiver pay minus everything else and that's your bottom line margin. you know, I am well aware that our margin of what we're charging the client at 35 ish and paying the caregiver 20.
No, it's below 35. I mean, the average of the existing clients, it's 34-ish and then the caregiver's making 22 on the agency side. That's a much smaller margin than what most companies are willing or able to absorb. And then of course, my staff is well paid and we have very rich benefits. So I have made a conscious choice as the owner, I'm 100 % owner of the company, to, I guess, make less money. Doesn't mean I'm...
destitute but I have made a life choice to not make as much money as I could, I guess. It feeds me in a different way to be able to take care of a lot of different lives that I know I'm impacting.
Miriam Allred (33:23)
Which makes me curious, which numbers are you focused on? Like if you're focused on impact and on sustainability, I get that and that's amazing. But I'm just curious the flip side of like what numbers, is it margin? Is it not margin? Like what numbers are you most preoccupied with?
Neal Kursban (33:45)
I I do meet with our VP of Finance on a weekly basis. I mean, the starting thing is cash flow. I mean, this sounds, I used to kind of give my mother a hard time. So I went on to get my MBAs, so numbers are a little more easily, you know, I can do a lot of things. But my mother, when I used to have meetings with her about money, she'd say, well, do we have enough money in our account to pay everyone?
And like, well, why are you complicating it? What else is there to talk about?
So in the purest form, I was raised like, if there's enough money, then don't overcomplicate things. So I'm not suggesting that, I mean, there are metrics and things, of course, to look at, but we do look at the, what's the rate, what's the margin, but it's not like a goal to aspire to what is it. It goes back to, to me, it's a very caregiver driven industry and business for us. And what is the market demand and what are we doing to exceed that? So we never have a worker shortage.
Never ever ever want to be in a situation where clients is I need care and I say I'm out of caregivers And they say well, isn't that your business? I? Say yes, and I always draw the Starbucks analogy imagine going to starboard. want coffee. Oh, we're out of coffee Starbucks like you're a home care company. So how in the hell you had a caregiver so anyhow I I don't I reject this worker shortage premise or this notion across the country that people are
are challenged with, I think there's things they could do internally to right that ship and not have to be in the position that they're in. you'd mentioned earlier, sorry, I'm gonna answer your other question, you mentioned we also, part of the reason why we have such low caregiver turnover, so the industry average is about four out of five caregivers aren't gonna be with a private duty home care company in a year, our average is 15 % turnover.
Miriam Allred (35:26)
Mm-hmm.
Neal Kursban (35:44)
So 85 % of our caregivers are still going to be with us a year later on average. And so why? Well, one, we pay them more. And then on top of their base wage being higher, they also get, we embrace overtime. So instead of them having to get a second job, if they want to work 60 hours a week, then 20 of those hours on the agent are overtime.
And so their average hourly wage is substantially higher than what I just mentioned. it's really, it prevents them from having to get a second job, because most people have a hard time living on less than 40 hours a week of care or only earning 18 to $20 an hour. So we have great retention on the caregiver side by paying, by allowing them to work more than 40 hours a week.
Miriam Allred (36:30)
want to ask us a few specific questions on this. Take kind of an average caregiver on the home care side. What's the average amount of hours that most of your employees are working? Is it that 40? Is it more than 40? What's kind of the average?
Neal Kursban (36:43)
No,
there's not. I mean, I think what's the average length of time the client gets care is probably the question. Because I think it depends. Some caregivers prefer they have a full-time job at the hospital and they want to pick up weekend availability. Or some work 3 to 11 at the nursing home. They can work 10 to 2, Monday, Wednesday, Friday. So it depends on what the caregiver, again, what do they want and what do the caregiver need? What does the client need and what does the caregiver want to work? And we, have a.
you know, a way to make sure that we don't, have a pretty good ratio of caregivers available per,
client that has their different needs. So it's not how much the average caregiver work. Those that work with us that don't work elsewhere definitely want at least 40 hours a week on average. Most of them probably work 60 hours. It's usually Monday through Friday. They're 7 a.m. to 7 p.m. or 7 p.m. to 7 a.m. is a very common thing. And some will work 12 out of 14 days and they want to work weekends. And oh, by the way, we pay them even more when they work on weekends.
All this is not charging the client any more money. They have a flat rate. So my margins keep getting smaller and smaller and smaller. And you make me, to answer your question, how do I have any money left? No, there's still, I mean, we do it on scale, because we're the size that we are, servicing the number of clients that we do.
Miriam Allred (37:56)
Yeah.
Do you have a minimum, an hour minimum for clients or you don't.
Neal Kursban (38:12)
In certain CCRCs or senior communities, we'll have no minimum. And then in private homes, we do have a four hour minimum. Like a house, if someone's living in a house, it's a four hour. Not that they could have it one day a week if they want. So we don't have a number of days a week minimum, but we do have a four hour shift, consecutive hour shift minimum.
Miriam Allred (38:32)
Okay.
I was curious because this is always the Rubik's cube of hours that the client needs and then filling that 40 hour schedule for the caregivers. Like this is the headache and just like the problem that we're constantly trying to solve. So I was just curious if you have minimums and what that looks like, because oftentimes that
that sets up the kind of 40 hour work week for the caregivers. You mentioned not being afraid of overtime and paying a lot of overtime. sounds like you even told me that you have some home care aides making six figures. I don't think I had ever heard that honestly in my time in home care. How is that even possible? We're talking these caregivers, these aides are working a lot of hours and getting a lot of overtime.
Neal Kursban (39:17)
I mean some caregivers and
some clients, whether it's live-in or working 12-hour shifts, working either five or seven days a week, and the family absolutely loves that caregiver and the caregiver wants to stay, and we're like, this is seven days a week, 12-hour shifts. And they're like, I know.
and you have no idea how many lives you're impacting, not just mine here, but the number of families I'm feeding back in my home country. And they are willing and able and happy to work 84 hours a week. I mean, they know the particular client isn't gonna live forever. So they're just happy as a caregiver often to have that client in that situation. And then the client or the family and the adult children love that caregiver.
I mean, I know my margins get much smaller, but hey, the client's happy and the caregiver's happy and it tends to have the case go longer than it may otherwise.
Miriam Allred (40:05)
Typically a big part to retaining caregivers for such a long time and having such low turnover rates, pay is huge and you're paying well. What about benefits? What benefits are you offering and what benefits are they taking advantage of that mean the most to them?
Neal Kursban (40:19)
Yeah,
we spend like seven figures in benefits for the caregiver. So it's very substantial. Health insurance, we give real health insurance just like my office staff. We give dental insurance. So we pay a lot towards the amount of health, the amount of dental. 90 % of the caregivers are enrolled in our 401K. We have an ongoing.
session of, again, this is the agency caregivers. I want to make sure I'm really clear. So if any lawyers are out there like, wait a minute. So the half of the business that we, I've been gearing most of this conversation towards that side of the business. Anyhow, 401k, 90 % participation rate. have 401k advisors that reach out to the care, like we have a monthly, we call it meet and greets, you hundreds of caregivers will hop on for that half hour to an hour and just whatever the,
Miriam Allred (40:55)
Great.
Neal Kursban (41:12)
And we have experts, whether it's 401k or financial planning or just life, like living life. And again, trying to just do our part to really take great care of them.
Miriam Allred (41:24)
And it sounds like a lot of these caregivers are taking advantage of these benefits. Sometimes that's the taboo of like you're offering them, but they're not interested or they're not tailored to them.
Neal Kursban (41:33)
I mean it's really an education.
I mean, I'm always conflicted, because I always feel like why aren't a higher percentage taking advantage of it, but then it doesn't cost me more money, me personally, to have them not do it. it's, well, we do a 401K match, I'm sorry, I forgot to mention we have life insurance that we pay for for the caregivers, so there's, I feel like I'm missing things. the other big one is we give hundreds of thousands, kind of in the carat,
with a carrot, not with a stick. so philosophically, it kind of ties in with caregiver and the service obsession. But we have hundreds of thousands of dollars worth of money given to the caregivers for for getting positive feedback from the families, from the clients. And so we have a...
just we're looking for positive feedback and then the caregivers know we're looking for positive feedback. They even ask us if the daughter called and said how's everything going and you they know when they're doing a good job and they know that they're gonna get a gift card or a gift certificate or gifts like they know they're gonna get rewarded for their for being who they are.
Miriam Allred (42:30)
That's awesome. I was going to ask how do you execute that? Is it mostly just gift cards or is gas cards or what are the things that they appreciate the most?
Neal Kursban (42:39)
I mean we've had these outsourced third party sort of, you can accumulate points and you go onto the portal and you can pick and choose all of the above. Some are gift cards, some are gifts, some are toys, think whatever it may be. They have a lot of different options they can pick from. And it depends on how many rewards they get and how much they want to save up and use it for later time.
Miriam Allred (42:49)
Okay.
Yeah,
it's all automated these days, these rewards and recognition platforms, which is really nice. But like you said, you're in, you're rewarding them based off client reviews, client feedback, positive client feedback, and then they get rewarded with these monitoring.
Neal Kursban (43:13)
And well, sometimes our
coordinators will put in a, you know, you were heroic at the last minute and I know, you know, they begged them and they went and they did an extraordinary job and they want to reward them beyond their base, you know, whatever their pay was. They want to just say, look, a boy, add a girl, great job, thank you so much, you're awesome, I owe you one. Because that's the reality of what happens in the coordinating world with the caregivers. And we just give them the tools to be that much more successful.
Miriam Allred (43:40)
Absolutely. The last thing I just want to mention here on the caregiver sustainability piece is you all started a foundation. You've got money in the bank to invest back into these caregivers. And so you created this foundation to help pay for CNA licenses and also clients that can't afford care. You actually help kind of offset some of those costs. Can you speak to just the philosophy of starting that foundation and then share any sort of like outcomes
Neal Kursban (44:07)
again, it's the same premise that we started this, tell me about your mother. So it's the least amount of cost to consumers and most amount of, know, so the caregiver's making this money. So we are not a 501C3, so we don't actually deliver the service. So we give the money to companies that service a lower income population. And then we also give monies to schools that give the scholarship money to caregivers that can't afford.
They want to get their CNA license, but they can't afford it.
Miriam Allred (44:36)
And then what about on the client side? appr- you come across people that can't afford care and you pay for a portion of it?
Neal Kursban (44:43)
Well, no. Again, we're not allowed, there's laws and limitations because we're not a, because we're a for-profit company that we have to recommend that they go to, there's a few different companies that service that population and then we give our monies into the foundation. It's the corporate profits, a percentage of that goes into the foundation and the foundation gives it to those third party companies.
Miriam Allred (45:04)
That's right. That's right.
Neal Kursban (45:05)
and then they're the ones
that will refer those families that call to those organizations.
Miriam Allred (45:09)
I think this is amazing and this has been, it's called the foundation, but this has been foundational since the premise of this business 50, almost 60 years ago is just giving back to the community, giving caregivers opportunities, helping clients pay for care. Like I think this is just so neat and I wish we could see more of this in the industry and home care margins are tight. Not every business has, lots of money laying around to be able to do this, but I think
This is at the root of what we do. And this is reflective of you as a business is, giving your excess money back to the two populations that you serve to create more long-term opportunities.
Neal Kursban (45:48)
But keep in mind, and I don't know if we have time to talk about it, we're not backed by private equity there's just nothing that forces me to have to do an X time frame with the fear that I'm gonna lose my job in five or seven years. Like there's just, it's just, this is what feels like the right thing to do and therefore I do it. there's no other pressures other than,
This just feels right.
Miriam Allred (46:18)
That's a good segue into this last this last differentiator, which is that you are still family owned and operated 100%. I would imagine that you have been approached over the years. What is at the root of saying no? Why Why do you say no? Why do you keep it family owned and operated?
Neal Kursban (46:36)
There's several reasons and yes, I get approached at least twice a day. I'm not exaggerating. Between phone calls and gifts that show up in my, I got another gift, like just to have five minutes of your time. So I get approached all the time. And I keep saying guys, there's no number.
I'm not interested in selling. This is very fulfilling for me personally. The fire still burns strong. I do have children and they're getting older and it's possible that, I mean, I'd like to provide at least the opportunity for the legacy to continue. Because I know what it's like statistically from one generation to the next to stay in business. There's a percentage of time it doesn't happen and then to go to another generation. so, you know, pulling the advisors have effectively
transition from one generation to the next. So I just want to keep the legacy going. don't believe that other...
There's very few companies that share this similar kind of culture and deliver the service in a way that families are truly grateful, like just emphatically grateful that we exist. mean, we get, again, one of the questions on our survey is, have you ever had a different home care agency before? And a third of them have. And it's like, wow.
third have gone elsewhere, now they're with us. So they're barred, and then they're just sort of amazed at the experience that they get from us, and they tell us time in and time out. Meanwhile, we have 97 % or 98 % of our clients that would recommend us, so guess 2 or 3 % wouldn't go to us in the future, but that's lower than 33%.
Miriam Allred (48:03)
So back to the question of turning down, no, you're good. Back to the question of turning these people away, the biggest thing, the biggest driver is just legacy and impact, but also confidence in what you can deliver and knowing or assuming that if an outside influence came in, you wouldn't be able to deliver at that same quality. Are there other factors or what else kind of goes through your mind in this?
Neal Kursban (48:05)
⁓ sorry.
I mean for me personally, you know, I have shared with some that I would love, this is, some people have their goal of if I can get to my company to be five million in revenue, I'll feel like I will have arrived.
or if I can get it to 10 million, or I can get to 3,000 hours or 5,000, however they measure their important KPI. So one of mine is when I get the company to be 100 million revenue, I can finally pat myself on the back and say, Neal, good job.
So it's just, I don't know why it's such an easy round number and I'm two-thirds of the way there and so, you know, and things are picking up steam so who knows how many years it'll be but so that's just, it's, I don't know, it's just my thing.
Miriam Allred (49:07)
It's just, no,
that's great. I like just the kind of the raw transparency of like how you think about this because every CEO thinks about this differently. I do want to circle back to kind of an interesting concept that ties into this, which is you have worn a lot of different hats and your role has grown and changed over the last 30 years. And something you shared with me is you
were really strong in growing the company from about 5 million to 40 million. And then you yourself felt like you got in the way and you hit kind of a plateau at that 40 million. But now today you're at six around 65. And so you have like identified your own strengths and weaknesses. Can you talk about what went through your mind?
and how you got out of your own way at that kind of $40 million mark because a lot of owners have this moment where they are in the way and it can happen at any revenue size, but for you, that's what it looked like.
Neal Kursban (50:00)
I think you're
a more effective leader if you're not constantly working. And so I was getting in that from five to 40 million, you know, the hours are starting to pick up and then.
know, sneaking downstairs as the family's going to sleep and working more more more hours to try to get the business to grow. And finally, like, is, I'm not scalable. I'm one person. And quite frankly, you know, so it took some looking in the mirror and recognizing that there's gotta be talent out there that's capable of getting past where we were sort of stuck.
And so today our president, Jeff, has tremendous skills and has sort of a scalability mindset and has really created an infrastructure in a way that has been very effective for us to get out of the issues I was unknowingly, I knew I was, I didn't have any fix them. I knew I was causing them, I didn't have to fix them. And I would read books and I'd talk to advisors and get a coach and I'm like,
And I realized, like, the Peter Principle, you get to your level of incompetence or incompetence. So anyway, and then in comes somebody else who has a different way of looking at things and just kind of riding that coattail. So it's been fun to see us get past that 40 million mark.
Miriam Allred (51:16)
Okay, that's interesting that you mentioned that because I was going to say, what did you do? Did you read? Did you hire a mentor and advisor? Sounds like you tried those things. They didn't necessarily work. What really worked and changed the game was hiring some outside influence that came in that you were compatible with, but you had very different philosophies and strengths and you probably just like pushed each other.
Neal Kursban (51:37)
Yes, very much so. And it's humbling because I'm actually a pretty competitive person, so it's like...
Can someone really do this better than me? How is that possible? And I got grit and determination, I'll do whatever it takes and on and on on. at some point, know, anyway, so it was very frustrating and it's been very enlightening and very empowering and very exciting to, yes, happen to have found a partner that just, are, actually we're philosophically aligned, share these very same principles, I mean, almost as if we were twins. And even though,
you know, the brother from another mother, ha ha. But anyhow, so philosophically we're quite aligned, but just how to go about achieving it and the levers to pull and the timing and the when and the how and the infrastructure needed, just all the things that Jeff's been, that he's brought to the company has been, it's been extraordinary. And I've learned quite, I personally have learned a lot along the way.
Miriam Allred (52:12)
Yeah.
Yeah, that was really well said.
Yeah, that was really well said, philosophically aligned, but not necessarily like operationally aligned. And something we failed to mention earlier was that when we were talking about margins is you burn through CFOs that couldn't philosophically get behind the charging the least amount of possible and paying the most amount of possible. You lost people that could not.
philosophically wrap their minds around that. But it sounds like you and Jeff can align on the mission and the vision and being impact driven, and that's enough.
Neal Kursban (53:04)
And my CFO is not Jeff, her name is Kira, and she's quite aligned in that regard and finds it to be, I've been told, an anomaly that someone is so determined to do so much for others.
So we're also aligned.
fact, my whole executive, like, yeah, they've been with me for so long now that we've all grown up and have been, and they've been promoted from within. And so a lot of our executives, we've...
We just, so long as, the only issue is if those become increasingly resistant to change. Because you cannot run the business the same way at 40, at 60 million, and 60, and 80 million, 80, and I think you have to do things differently. And it's the only challenge at times has been those that have been in denial that they're being resistant.
Miriam Allred (53:50)
Mm-hmm.
Hmm.
Which is more relevant than ever in home care. I think every business could draw parallels to what you just said, but especially in home care, just everything looks different at different shapes and size and different, like milestones. And so you really have to be agile and nimble and open to change as you scale. have one last question for you, Neal, and I'm putting you on the spot with this so you can take a minute to think about it.
You talk about scaling to maybe a hundred million dollars. That's no easy feat going from where you are to where you want to get to. What are some of the core components that you can predict will be a part of that growth? Like what, if you don't know it, you don't know, but what are some of the things that you think you will need to explore or change to scale to that size?
Neal Kursban (54:44)
I just think we'll gradually get there, just like we've gradually gotten to where we are. mean, our company grows on average about 8 % a year, and we just grow.
And so it's tweaking so many things internally. Sometimes there's big, massive, substantive seismic changes that happen every X number of years, but usually it's tweak, tweak, tweak, tweak, tweak, and then you're just kind of growing a little bit more than what you were, and then you have to go through a seismic change every five to seven years, and then you tweak, tweak, tweak, tweak, and then you grow. So, I mean, it's just, we'll just gradually make it happen. There's no...
Miriam Allred (55:18)
So it's mostly demand
driven. Like there's just the opportunities there and the demand will.
Neal Kursban (55:23)
Well,
if we never had a worker shortage, and I don't envision we will, and the Baby Boomers haven't hit 85 yet, I just think the opportunity is, it's huge. It's huge.
Miriam Allred (55:33)
Can I ask you to predict one of the maybe seismic changes that you could foresee? Technology overhauling like internal team, like if you could even kind of predict one of those seismic changes in the next maybe 10 years, what do you think it could be?
Neal Kursban (55:51)
I would love to say, and this is probably controversial, but I would love to offer the option of having robots do home care.
And I'm not saying the entire fleet of caregivers would be robots, but I do think there are some clients and families out there that would prefer to not to feel like they have to quote unquote entertain the caregiver. And knowing that it's not a human, but they get their needs met that actually, I know it flies in the face of conventional wisdom and some people might find this very controversial. But again, just a percentage of if technology really grows to the point where robots can do it, do ADLs.
I would be fully on board and look forward to being on the early side of experimenting with that.
Miriam Allred (56:33)
I like the hot takes, the controversy here. Neal is pro robot. Like you said, there's so much that we don't know. There's so much in development right now, but it sounds like there are families and clients that are open to it that would benefit from something like that. And so just more exploration on that technology side.
Neal Kursban (56:53)
Yes. I mean, can say more if you want, but yes.
Miriam Allred (56:56)
Yeah, yeah,
no, I think it's just interesting to be honest. Like you said, it's controversial. think everyone most people would say that
Neal Kursban (57:02)
But there are,
I guess I said this, I wanna double down on it. There are a percentage of older adults that really don't, sometimes people are like, what are they gonna do all day? I don't need a caregiver. What are they gonna do? And the adult child's like, just the insurance, the mental insurance policy of knowing there's a caregiver with mom is the peace of mind.
And that, knowing that they also don't have to worry about what the caregiver is thinking and feeling actually is a factor into why people may be resistant to getting a caregiver in the first place. But if they knew it was a robot and the robot has been tested and they weren't their first client, then they'd be open to it. I just think there's a segment of the population that would prefer it.
Miriam Allred (57:43)
This is after show. Here we go. Are you exploring any smart home automation technology currently offering anything?
Neal Kursban (57:45)
It's not what do I want, it's what do the clients want. Go ahead.
No, I'm all about outsourcing to find the best that's out there that offers that. I'm not one to let me also have a side hustle or a side business going to offer something. I think there's companies that spend hundreds, millions of dollars of their technology and I would wrap it around what we do, but I wouldn't want to start it from scratch.
Miriam Allred (58:21)
Okay, yeah, that's kind of what I meant. Like, you are you packaging anything any other software technology into your services?
Neal Kursban (58:28)
I have sampled and I've been underwhelmed continuously and consistently underwhelmed. The technology of this industry is by far the most frustrating part for me of the home care. The basics of having a great caregiver go to the home.
Miriam Allred (58:39)
Mm. Mm.
Neal Kursban (58:43)
I'm not saying it's easy, but that's controllable. It's relying on others to help wrap around what we do and do it consistently. And with a wow mentality, it's not been consistently reliable. And I've had to go through a lot of different business partners to have worked for periods of time and then have to move on.
Miriam Allred (58:46)
Mm.
Hmm.
Well, it's people like you that push us. We've come a long way in the last 10 years, but we do have a long way to go the next 10 years when it comes to technology.
Neal Kursban (59:11)
be incredibly unrelenting in doing so. I will
never, I will always be relentless in this pursuit.
Miriam Allred (59:18)
Again, I think we need people like you to push us to be the best that we can be in home care.
We've got an uphill battle to climb yet, but we're inching closer. Neal, this has been awesome. I know I have thrown a lot your way and sometimes episodes are focused on one topic. This was kind of three in one. and I think you really held your own and did a great job. we were talking before this call that you've sat on a lot of boards, a lot of people know you, but I just love hearing this story and hear you dial through some of these core areas of your business. So thank you for joining me in the lab and
Thank you for being prepared for the conversation today.
Neal Kursban (59:53)
It
was an honor to be invited and thank you very much, Miriam. Thank you.