Fred Johnson’s Big Idea That Might Change Nursing Care

This program truly does change the world substantially, particularly for these patients and their families, in the following ways:

It enables these children to be at home and remain home because they are now receiving the consistent care they need every single day.

We’ve treated over 1000 patients in Colorado with this model and our 30-day rehospitalization rate for our patients is approximately 3%, compared to the national average of 18%. This saves Medicaid a tremendous amount of money on the expensive ER visits and extended hospital stays.

Our program also saves states an average range of 20–40% for every hour we can replace a nurse with a Certified Nursing Assistant or Certified Home Health Aide.

We train parents and family members for free with absolutely no strings attached. If they don’t pass all their exams, testing and clinical training, then we write off the cost completely.

We often can get these families completely off food stamps and welfare by providing long-term employment, hence saving states even more money.

For any parent or family member who works more than 30 hours per week, we also provide a full health insurance benefit package for them and their family, 401k, and continued clinical training that can even allow them to use their clinical training for employment outside the home if their situation enables.

Our robust data analytics capabilities also allow us to provide Medicaid agencies with precise numbers on cost savings, reductions in hospitalizations, and other key financial and medical outcomes.

As a part of my series about “Big Ideas That Might Change The World In The Next Few Years”, I had the pleasure of interviewing Fred Johnson, President & CFO of Team Select Home Care. He is primarily responsible for directing the finance, operations, and growth functions of Team Select. He possesses 20+ years of global Fortune 500 experience across multiple industries, specializing in Finance, Strategy, Operations, Data Analytics, and substantial M&A exposure. Completed an undergraduate degree in Accounting from the University of Wisconsin — Madison, an MBA from Cleveland State, and an Advanced Certificate in Data Analytics from Cornell.

Fred and his team at TSHC are on a mission to shine a spotlight on the high-risk population medically fragile children and their families. In October of 2020 they launched The Unforgotten Families (TUF) to provide a resource of support to the community of families faced with the challenges of caring for a medically fragile child to they can learn more about the Family CNA Program.

Thank you so much for doing this with us! Before we dig in, our readers would like to get to know you a bit. Before we dig in, our readers would like to get to know you a bit. Can you please tell us a story about what brought you to this specific career path?

I spent almost 20 years working for a few global manufacturing companies in the Aerospace, Defense, and Industrial markets. It was fun and rewarding for a while, but difficult on my wife and children, as those 20 years included 18 relocations across the US and Europe. My best friend from graduate school, Mike Lovell, founded Team Select Home Care in 2008 and eventually recruited me from “Corporate America” in 2014 to join him in building something special and innovative. Once I met the Team Select team and learned more about the business, particularly the new Pediatric division that had recently been launched, I was hooked on the idea of helping build something that could truly make the world a better place for medically fragile children and their families. I had lost my passion and purpose in the Corporate world and felt the need to use my energy and talents in an industry desperately in need of innovation.

Can you please share with us the most interesting story that happened to you since you began your career?

Probably the craziest and most interesting thing happened prior to joining Team Select and the healthcare industry, that had a profound impact on my personal life and eventually my career happened in 2012. I was spending a lot of time working in the Middle East, and I ended up catching the world’s rarest parasite. It was a little scary. I lost over 20% of my body weight and was sick for a very long time. I eventually got past it, and while it was a rough time, I feel it made me a better person in the end.

Once the parasite finally died, the “western” traditional doctors were pretty much done with me, but I was a shell of my former self. I turned to a friend who was a health coach, and she guided me through an array of holistic medicine practices to naturally rebuild my gut, body, and brain back to normal after months of toxic and aggressive medications and no solid food or exercise. She helped me come out the other end a much more spiritual person, not just more in touch with myself, but seemingly more in touch with others and more empathetic for people dealing with difficult medical conditions. I believe this was the main catalyst that prepared me to leave the big-company corporate life for something more meaningful and impactful.

Which principles or philosophies have guided your life? Your career?

1. It took me almost 20 years of my career, and joining Team Select, to finally discover what has become my career mantra, not just for myself, but for all of Team Select and our employees. It’s a take on a Japanese philosophy called Ikagai, and essentially it says that the happiest people in the world (and I believe the happiest and strongest companies) find the intersection of the following four elements in their career:

• Do what you love and enjoy doing
• Be great at what you do
• Be paid for what you do
• Make the world a better place

2. Those four things have become the root and lens for how I help lead Team Select, how we choose what service lines to pursue, what we screen for when hiring employees, etc. It’s really become a powerful force in my life, and I can absolutely say it works!

Let’s now move to the main focus of our interview. Can you tell us about your “Big Idea That Might Change The World”?

1. Due to the worsening national nursing shortage, recently compounded even more byCOVID-19, medically fragile children and their families struggle to receive the consistent in-home nursing care Medicaid is obligated to provide for them in order to keep them safe, healthy and out of high-cost and risky hospital and skilled-nursing facilities. Pediatric home health skilled-nursing companies are generally in place almost everywhere nationally to provide this care, but they are beleaguered by stagnant Medicaid reimbursement rates and difficult workforce challenges, as home care pediatric nurses typically make significantly less money than their peers in facility settings.
2. One unintended consequence of this dilemma is that it drives a majority of these families to divorce from the constant financial, physical, and emotional toll of raising a medically fragile child, especially when in-home nursing care is unavailable or inconsistent. This also has the unintended effect of driving many parents to unemployment, food stamps and welfare, as they often find it impossible to hold down meaningful employment outside the home because they are routinely forced to call off work or remain unemployed in order to attempt to care for their medically-complex child without proper training or oversight. The other alternative is to place their child permanently back into the most expensive facility settings allowing them to work outside the home to provide for themselves and the remainder of their families.
3. The clear long-term common goal for everyone involved, including Medicaid, is to drive these patients into the home and keep them there. However, instead of driving more children into the safest and lowest-cost setting (the home), we are now seeing more and more children being pushed back into hospital and facility settings because home care companies are unable to consistently staff the nursing hours needed to keep these children at home. Many of these children are already on respirators and the COVID situation makes these settings incredibly dangerous to these high-risk and susceptible children.
4. Data consistently supports the fact that these children remain healthiest and happiest, and have the lowest total cost of care, when they receive the consistent home care they need and are authorized to receive every day. When they don’t receive the daily home medical care due to nurses being unavailable, this frequently triggers high-cost ER visits and extended hospitalizations, which are over 10 times the cost of in-home care per day. The data also shows that it’s not the professional level of nursing care the children receive in the home, rather the consistency of the care they receive in the home.
5. Based on those factors, our program is innovative, incredibly simple and practical, and frankly has been there for us all along. We call it our Family CNA Program. What we do is leverage parents or other family members and train them for free, with no strings attached, to become Certified Nursing Assistants or Certified Home Health Aides. Assuming they pass all levels of certification and clinical training, and depending on the acuity level of their child, we hire them as caregivers and replace some, most or even all the skilled-nursing hours their children would historically receive from outside nurses. From experience, we can absolutely say that a parent or family member almost never misses a shift and that helps ensure these children receive that necessary care every day to keep them thriving at home.

How do you think this will change the world?

1. We’ve already seen this program drive life-changing improvements for these families in Colorado for over a decade. However, until very recently, this program has not been adopted, or much less even considered, in other states. Thankfully, there is a growing awareness and momentum driving new states to begin considering this model. Recently Arizona and Missouri have both passed legislation to begin bringing this program to reality by the end of 2020.
2. This program truly does change the world substantially, particularly for these patients and their families, in the following ways:

• It enables these children to be at home and remain home because they are now receiving the consistent care they need every single day.
• We’ve treated over 1000 patients in Colorado with this model and our 30-day rehospitalization rate for our patients is approximately 3%, compared to the national average of 18%. This saves Medicaid a tremendous amount of money on the expensive ER visits and extended hospital stays.
• Our program also saves states an average range of 20–40% for every hour we can replace a nurse with a Certified Nursing Assistant or Certified Home Health Aide.
• We train parents and family members for free with absolutely no strings attached. If they don’t pass all their exams, testing and clinical training, then we write off the cost completely.
• We often can get these families completely off food stamps and welfare by providing long-term employment, hence saving states even more money.
• For any parent or family member who works more than 30 hours per week, we also provide a full health insurance benefit package for them and their family, 401k, and continued clinical training that can even allow them to use their clinical training for employment outside the home if their situation enables.
• Our robust data analytics capabilities also allow us to provide Medicaid agencies with precise numbers on cost savings, reductions in hospitalizations, and other key financial and medical outcomes.

3. Overall, this program really hits the four principles we strive for at Team Select, which are (1) Do what we love and enjoy doing; (2) Be exceptional at how we do it; (3) Drive positive financial results for all involved; and most importantly (4) Make the world a better place.

Keeping “Black Mirror” and the “Law of Unintended Consequences” in mind, can you see any potential drawbacks about this idea that people should think more deeply about?

1. Designed and executed improperly, like any Medicaid benefit program, there could be an opening for misuse or abuse. However, designed properly, and proven in Colorado for over a decade, this solution is almost bullet-proof from a cost savings and care quality standpoint, with little or no risk of unintended consequences. To ensure this, we only recommend the program be implemented with the following regulations:

• Only children who are deemed medically fragile and who currently qualify for skilled nursing care in the home are eligible for this program. Hence, we do not introduce any new beneficiaries into this benefit.
• We never work a single hour more than is prescribed by a physician and authorized by Medicaid. Whether the case is still staffed 100% by a nurse, 100% by a CNA or CHHA, or the combination of the two, we will never work or bill for one more hour of care than authorized. This helps us essentially “guarantee” any state that adopts this program will undoubtedly receive a cost reduction.
• We ensure all our parents and family members are not paid whatsoever to perform routine parenting duties. They are only paid to perform medically approved tasks previously performed by a nurse, such as: g-tube feedings, bowel care, advanced personal care with activities of daily living, etc.
• Every clinician in Team Select receives a GPS-enabled tablet, which helps us guarantee every parent or family member is in the home when the care is being provided, at the times and intervals authorized by a physician and Medicaid. Our tablets and associated care plans walk clinicians through every part of every task with documentation before moving on to the next item in the care plan.

Was there a “tipping point” that led you to this idea? Can you tell us that story?

1. I became instantly attracted to our Pediatrics business when I joined Team Select in 2014, but it was a few years before I really was able to fully understand what life is like for these families and the challenges they face. I made a point to visit and befriend a handful of families in Arizona and Colorado, where we initially had our Pediatrics home health operations in place and became shocked at the stark differences between the families of the two states.
2. Our children and families in Colorado were consistently thriving, while families in Arizona remained burdened with the multitude of effects the nursing shortage has on every aspect of their lives. Additionally, our teams in Colorado that lead and provide this care were our happiest employees by far with very little turnover. They felt like superheroes every day by helping to employ parents in need and providing them benefit packages, dramatically improving the consistency and quality of care these children receive, ensuring these children wake up to a loving and smiling parent or family member every day, all while saving the state of Colorado significant dollars that can be freed up to help Medicaid agencies redirect those critical and limited funds to help other beneficiaries in need.
3. The final tipping point for us happened when COVID-19 hit and took this problem to a whole new level. The nursing shortage, which was already acute, has intensified even more as nursing demand skyrockets from COVID. This is driving more of these home care cases to go unstaffed, which has the incredibly dangerous and expensive consequence of trapping these vulnerable children in hospitals, unable to discharge due to lack of available home nursing staff. This problem is further compounded by the fear that both nurses and families have about others coming in and out of the home during COVID. That has led to some nurses afraid to go to work and parents afraid to let the constant stream of nurses in and out of their homes. That was when we all decided, if no one else is going to start pushing for national awareness and action, then it may as well be us. We couldn’t stand by any longer and watch these families suffer, knowing there’s a proven solution that’s already been perfected and proven to work. We’ve started to nationally advocate more publicly, spread awareness, and partner with families, non-profits, children’s hospitals, and even competitors to help convince states to adopt this demonstrated program.

What do you need to lead this idea to widespread adoption

1. We were trying to do this mostly on our own, in the background, with limited resources and funding, for the last several years with very limited success. We’ve had multiple Governors and Medicaid agencies embrace the program and promise change. However, things always seem to get bogged down while trying to work with Medicaid agencies due to red-tape, outdated regulations, and their limited resources to devote to innovation and change. At this point, we’ve realized the only effective way to move forward is to embark on a national awareness campaign while partnering with groups that can help us move this initiative forward.
2. We need to better educate stakeholders and show them that the solution to this decades-long problem has been right in front of all of us the entire time. Most importantly, we need people to not just be aware, but to ACT! I think sometimes it seems “too easy” to decision makers or “too good to be true”, and they feel they have to be “missing something”. The reality is everyone really does win with this program. The children, families, home care agencies and Medicaid all benefit. Nurses also gain, as we free up scarce and valuable nurses to work at the higher end of their licenses and earn a higher wage by only performing the higher acuity medical tasks they are trained to provide, while delegating lower acuity tasks to CNA’s and CHHA’s. It also opens the doors for these precious pediatric nurses to advance their careers by becoming RN Case Managers, Clinical Supervisors, Directors of Nursing, etc.
3. Visit https://teamselecthh.com/family-cna-program/ to learn more.

What are your “5 Things I Wish Someone Told Me Before I Started” and why? (Please share a story or example for each.)

1. “Being responsible sometimes means you’re going to piss people off.” I spent too much of my career trying to make everyone like me. Through this process, I’ve learned that to drive substantial change, sometimes you need to be willing to rock the boat and stand up for what you believe in, even if it means some people aren’t going to like you. In this case, I’ve spent over two years playing nice with Governors, Legislators, Medicaid Directors and more, but unfortunately the proactive partnership approach hasn’t produced the urgency required to make a significant impact. Hence, our reasons for embarking on this national awareness campaign to create a groundswell of public pressure and momentum to push those responsible to act.
2. “It’s lonely at the top sometimes.” For every person I’ve engaged who supports the program, there are way more who try to convince me that even though they may agree with all aspects of this program, that the fight is just too hard and time consuming to come to fruition. This has done nothing except strengthen my resolve and efforts, however, it sure does feel a bit lonely and frustrating at times, especially at the rate of change that states are willing and able to act and innovate.
3. “Don’t be bullied or intimidated by so-called authorities and the privileged.” It’s taken me a while to have the courage to stand up for these children and families to very powerful people and so-called “authorities” who cling to outdated beliefs and mantras and who live in fear of change.
4. “Don’t assume everyone will have your same passion.” I’ve listened like crazy, educated myself considerably, and have sought to position myself as a bit of an expert and advocate nationally for these children and families. I’ve spent every day of my life for six years trying to help these families. It’s so painfully obvious to me how much this program is needed, especially in the new COVID world. However, again, I’ve learned the hard way that common sense and practicality aren’t often enough to drive change. So while I still leverage the “human” and “emotional” elements of this problem and program, it’s critical to show and demonstrate all of the supporting data that shows, beyond a shadow of a doubt, that this program drives both substantial cost savings and improvements in the quality and consistency of the care.
5. “You can’t do this all on your own.” Resistance to change, even the most obvious and practical change, is extremely hard to accomplish when dealing with government bureaucracy. One person or one company isn’t enough.

Can you share with our readers what you think are the most important “success habits” or “success mindsets”?

1. From an overall standpoint, separate from this initiative, the following principles guide me and I have them posted around to consistently remind me:

• As a leader, seek to be respected, not feared. My father told me that when I was first entering the workforce and it’s stayed with me for over 25 years and counting.
• Be charitable with your time, talents and money.
• Don’t try to do everything, so you can be excellent at what you choose to do.
• Never let your honesty or integrity fail you.
• Just be nice and have a sense of humor.

Some very well known VCs read this column. If you had 60 seconds to make a pitch to a VC, what would you say?

Myself, Team Select, and our partners are not advocating for this population for investment purposes. From a financial standpoint, we actually receive less money from Medicaid for providing these services while also bearing the high cost of providing free education and training for parents and family members to become Certified Nursing Assistants or Home Health Aides. We are doing it because these children and their families, and even states and Medicaid agencies, desperately need a solution to a problem that has plagued this patient population for decades, and is now accelerating at a pace where the problem is getting worse by the day.

As a company, we are fortunate to be able to help, and based on our core values, to us that means we are compelled to help. If I had 60 seconds, I would direct my response to Governors and Medicaid Directors, who together have full power to implement this program quickly.

To Governors and Medicaid Directors — Your state and Medicaid have an obligation to provide services that enable children with chronic needs to live at home with their families. The home is by far the lowest cost setting, and where these children are happiest and healthiest. Not only are you not meeting that obligation, but by keeping home nursing reimbursement rates so low, you are actually spending significantly more money overall to care for these children by incentivizing them to return to ER, hospital, and nursing facilities, often with no hope of being able to return home due to the nursing shortage.

I’m sure stakeholders have been screaming and pleading for years for you to raise home health nursing rates. You can and you should. However, by implementing this program, not only could you fund an increase in the nursing rate, but you would save millions of additional dollars at a time when your budgets need it the most.

Any relief to the nursing shortage is at least 5–10 years away. There is nothing to fear here and nothing to hide. This problem is truly a matter of life and death. It’s time ACT NOW before more innocent lives are lost.

A massive wave of children and parents, along with non-profits, hospital groups, home health companies and more is coming, as we have recently begun banding together as one united force. These parents are knowledgeable about their rights and they are relentless in their pursuit of what they deserve. Don’t wait for them to come after you with lawsuits like those recently in IL and CA that led to huge rate increases.

This small, but incredibly vocal and influential group may make or break your career in the next few months, as a significant, coordinated PR effort is in the works. You will be called out in one of two ways soon. You can either be called out as innovative, empathetic, and visionary; or you will publicly be called out for lack of action and empathy for these vulnerable children and their families. It is absolutely the type of PR that kills careers and reputations.

Remember, it’s not the level of care, rather the continuity, that drives down the total cost of care for these children and drives the overall quality up. Don’t just sympathize, make an impact and ACT!

Thank you so much for joining us. This was very inspirational.