This week I am talking to David Hunt, Founder & President of the Cosán Group – which is Gaelic for path, a path that David has been on since growing up in the Boston area with a tight knit family. His career started out in the Medicare world which provided some early insights into the challenges of supporting older generations as they navigate inevitable health challenges and the over riding desire to stay at home.
His early roles found him in patient homes where he realized there was so much more to learn about an individual that could not be gleaned from an office based interaction. As he spent time with people in their home setting he found it rich with insights, between the pictures on the wall, the dialogue, he got to see what kind of people they were, what their family was like, what their hobbies were, and where they had worked. Was Dave pointed out – this was the time they discovered the person could not get up the stairs in their house or had no food in the fridge – critical information. One of the key discoveries was that of 99490; the care coordination code.
They worked on building out the services that augment the clinical interaction, taking over actions and follow up from a clinical visit. This function is something that some families have a resource that gets involved and coordinates and and gap they wanted to fill. But even when families had their own resource the coordination across geography and distance was difficult.
Listen in to hear about “Eleanor” the voice automation and how they have managed to integrate this into their systems to create a scalable solution that allows one skilled clinical resource, who can be located in another state, who is able to support up to 350 patients. Find out how they have integrated their team and solutions so that their staff know more about the patient than the clinicians do and hear his persona story and journey with his family and parents as even they struggled to navigate a smooth experience for his parents dealing with medical issues and coordination despite being located in the medically rich environment of Boston
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Raw Transcript
Nick van Terheyden
Today, I’m delighted to be joined by David Hunt. He is the founder and president of the CO San group. David, thanks for joining me today.
Dave Hunt
Thank you for having me, doctor. Appreciate the time.
Nick van Terheyden
So tell us a little bit about yourself, we’ll get into the cosine group in the area of focus. But first of all, tell us about you and your journey to this point in your career.
Dave Hunt
I appreciate it. Yeah. So originally from Boston, Massachusetts, and, you know, grew up in a pretty, pretty close, tight knit family environment, got into marketing early on in my career, looking at member acquisition for some of the larger companies like Aetna and Cigna around their Medicare marketing. And, you know, I ended up moving into a space where I went down to run a large rehab company, so physical therapy, occupational therapy in the home, which I really, you know, for me, coming from an environment where my grandparents and, and relatives were pretty important elements of my life, the dealing with older adults was something that I was, you know, really enjoyed for a long time. And so getting into the rehab space for older adults was something that I found very fascinating. And so we would see these individuals, and we were across nine states at the time, but 1000 clinicians, and calling on providers, you know, across all these states that 1000s of riders, and I would go out with our clinicians into the home, and you know, two or three days a week, you’d be meeting with these individuals, and you would learn so much about these folks, right, which is different, because I, you know, somebody is going to open up to a physical therapist, or an occupational therapist or myself, if I would join them a lot differently in their home environment, you know, over the course of an hour, and you learn, you know, between the pictures on the wall, between just a dialogue, you get to see kind of who these people were, what their hobbies were, where they worked, what their upbringing was their family environment, it was just fascinating to me. So I was looking for ways to connect, because we had, you know, our way of getting access to these individuals was sending a Salesforce out to the physicians. And I used to call them donut dollies, because really, we would walk in with Dunkin Donuts. And we’d say you got it, you got a, you know, therapy referrals for us that we could use, which wasn’t all that efficient, frankly. But it was
Nick van Terheyden
not that healthy either.
Dave Hunt
Not that healthy. No, not that healthy. But you know, much, much goes a long way. The easiest way behind the front desk of physician practicing pretty much. But you know, it’s we got the referrals and what have you, this is kind of efficient, here we are inefficient, sorry, we’re in the home, we’re seeing what’s going on with, you know, folks that do not have food in the refrigerator, or they’re sleeping on a recliner, because it’s too afraid to walk upstairs. And that to me was just, you know, information that could be pretty valuable to the provider in thinking about ways to help that individual age more successfully. And so I was looking for ways to do that. And the, you know, initial was, let me fax you a bunch of information or send it to you. And then you know, the providers. And I understood were saying no, don’t do that. You know, because then we’re liable if we miss something, it’s a lot of additional information, we don’t know what to do it. And so I was looking for ways to make that more efficient, get away from the donut dollies and kind of incorporate ourselves into kind of the health care continuum in a different way. And found the chronic care management code 99490, which was 20 minutes of non face to face care coordination. And the thought was Jesus is a great way to kind of get inside the practice environment and connected and so I made the decision back in 2015, to start co sawn which in Gaelic his path and thought this is a this is kind of the next journey, you know, funny kind of semi funny at the time. I don’t know if it was all that funny, but I went to a show called prime Med, where there were a lot of physicians and after creating this SAS software model to go after chronic care management, I stood up in front of about 500 physicians and I went through this hour long pitch about I think this is going to change you know how we work with patients looking to give you a lens into the home environment. At the end of the hour long pitch I asked you know how many people are going to do this and I saw one hand go up in the back of the room and it was one of those oshit moments. You know, like I don’t know if this is a great career move right? So I stuck with it did the same presentation in 16. Same presentation and 17 started to get a little bit of adoption. Did a little work with back in the rehab space and kind of kept coasts on going and 18 We looked down we’re like cheese we have 50,000 pieces In our system, you know, and a lot of providers using this. And so this is really starting to make some sense. You know, 19, you know, we had five employees, and we thought, you know, alright, let’s, let’s make a little deeper run at this, we’re starting to understand the space, they’re adding additional codes. And, you know, we merged with chronic care management, Inc, which was also looking at this space kept the Kasan name, early 2020. And, you know, now today, we set at 176 employees, between our full services, SAS doing about 50,000 episodes on a monthly basis, working with providers across the country, and, you know, prospects for growth going forward, are, are quite solid. So, you know, really, it’s been an interesting journey over the last, you know, specifically 11 years managing in this older adult environment, kind of switching sides from marketing to an older adult, on behalf of, you know, some of the larger insurers and providers to actually being on the other side, where we’re delivering clinical care and clinical value on behalf of providers.
Nick van Terheyden
You know, fascinating story, it sort of emphasizes one of the points that I keep making, which is, you know, it takes 10 years to be an overnight success. And, you know, you’ve you’ve sort of felt that for real? Yeah, you’re in a space that is just extraordinarily important, because of the changing numbers that we have not just in this country, we’ve seen it in other countries, but, you know, certainly we’re seeing the impact of this aging population that we’re struggling to support. And I, you know, I’ve heard others say this, I’ll say, you know, there’s, there’s not a single person I know, who is aging, who says, I want to age in a home, they want to age in place, right, and you’re trying to create an environment. Tell us a little bit about what cause does and how it goes about that?
Dave Hunt
Yeah, that’s good. Great question. So if you think about the relationship between an older adult and the provider, it’s a pretty strong relationship for most in most cases, right. But it exists within an exam room for the most part of 1520 minutes. And whether that’s a monthly or quarterly or, or, you know, a few times a year, you know, that experience because providers have been so constrained, right? They go from this notion of a home delivery many years ago, of a clinical service to brick and mortar, to seeing, you know, 2025 patients a day. So the whole environment for providers has changed so that that ability to get very personal and understand a little bit more about that individual has kind of been added not because they don’t want it, that’s not the case at all. It’s just because the time doesn’t there. There’s a lot more constraints around them, right. And so what we do is we work on behalf of the provider, outside of that 1520 minute exam room visit, right? So we remote into their EMR, electronic medical record into the patient’s chart, and we become to some effect the the eldest daughter for that older adult, right, or at least a kind of a support mechanism. So the minute they walked out of that exam room, were working with them because the provider asked them, we need to get you some lab work. Alright, can we help you schedule that? Do you have a ride to get to that lab work? You need to go see a neurologist? Let us help you schedule that? Do you understand why you’re going to see neurologist? You were just prescribed a new medication? Do you know why you were prescribed that medication? Do you understand the dosage? Do you understand the frequency of what you should be taking it right? And then throughout the month, there is kind of planned engagement, right to make sure that they continue to follow up on those referrals. But there’s also kind of proactive and reactive engagement, meaning that we use our care teams to reach out to say is there you know, you started to take that medication? How are you feeling? Right? We also use voice bots that reach out it says anything you want to share with your provider. And so we’re trying to give you know the the you know, events happen, typically somebody is not going to fall or somebody you know not going to have an episode of care inside The Exam Room or waiting in the you know, the waiting here, it’s going to happen in their home environment where they are 99% of the time, right? And so what we’re doing is we’re giving a lens into that home environment, and we’re giving a resource to that older adult to communicate back to the provider in shorter increments. And within those shorter increments, we actually can affect some some change, because we can have the clinical interventions take place as close to the event as possible. And we can actually monitor a change in health status as close to the event taking place. Should there be something that goes south, right? And so today, older adults are very resilient. Right? They I’ll be fine. Right? You know, I see it in my own parents, I’ll be good, I don’t need to get right. They just, they’re tough group, right. And so they wait, I have an appointment in three months, I’ll go, you know, or three weeks, I’ll go see them, then I’ll talk to him about it then. And then they forget how they were feeling, or they stopped taking the medication. So many different things that take place I fell, but that’s okay. I’ve fallen before it’s it’s not a big deal, right. And it was just a bump, it’s just a gash on the head or something, I’ll put it. So there’s always an excuse, why not to communicate, and we’re looking to do is to say, Hey, we are here to support you, regardless of what you need here. Help us communicate anything that’s to the provider that will help us keep you out of the hospital, keep you from falling, keeping from you having a concern around your medications or some you know, negative effect of those medications. And that’s really what our objective is where we’re a guide, we’re lens with a provider, and we’re a guide for the patient.
Nick van Terheyden
So I mean, clearly, highly valuable in the context for an awful lot of people who don’t have, you know, that resource within the family. But how do you scale this? What’s the sort of capability because this sounds very intensive. You talked a little bit about some tech, but it feels like that’s a sort of central component to making this a, a truly scalable answer to the burgeoning problem of you know, the silver tsunami, as it’s called by sun.
Dave Hunt
Oh, yeah. No, Tech is a vital, right. And so whether we’re using devices to track blood pressure or weight, right, or we’re using voice bots, to reach out in, you know, the caller, Eleanor. So, you know, it’s funny, if you look back about a year ago, I had providers saying I don’t want the patient’s talking to robots, right. And today, I show him what Eleanor is capturing, like, everybody should talk to Eleanor, right. So no longer it’s no longer a robot. It’s, it’s all about Eleanor. And so every older adult has a care coordinator. We’re doing everything, the bulk of what we do is remote. So our care teams are working from their homes in a secure environment, right. And, and so we can, because we can use their licensure across states. I have care team members in Hawaii, and Texas and South Dakota all over the place. So I have access to a very, very deep pool of clinical professionals that I can leverage, right. So medical assistants, LPNs, RNs, OTs pts. So from a ratio standpoint, I could put one individual with around 350 patients. Right? Now, I augment those individuals with technology. So that could be tracking vitals through devices, it can be through Alan or the voice bot, which has a very low cost of delivery, right? It calls up and says, Mrs. Jones, how you doing today? Is there anything you’d like to share with our provider? Do you want your care coordinator, Susan to give you a call, and it transcribes that information and sends it directly back to our care coordinator. And they can see Mrs. Jones who said she has fluid building up in her leg, we pick up the phone we call. So we’re we may be a ratio of 350 to one. But that’s actually extended because we use technology to pinpoint the people that we want to talk to at that point in time. Right. And that’s how you scale it. You have to scale it through technology, you have to scale it through pods, and you have to scale it through being preventative, right and proactive. Right, when you’re just reactive. Now, if you’re sitting at the front desk of a provider’s office, he just handling all the calls coming in. It’s because it’s got to a point where if somebody had to make the call, so it’s gonna become more urgent, right and more, you know, reactive and having to do it at that point where we’re capturing things as they start to happen. So we can address them in a easier way and smoother way and more efficient.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist today. And I’m talking to David Hunt, he is the founder and president of the cosine group. We were just talking about the augmentation with technology. And, you know, the use of voice bots, an area of sort of passion and interest of mine, one of the things that, you know, stands out in that is that, interestingly, people are more honest with those technology interactions than they tend to be with human beings, particularly with difficult topics, even though they know that results in a human interaction, you know, so they’ll be very honest. It was a surprise to me at the time, but I think it’s it just sort of diffuses the circumstance. You’ve all mented you have this wide scope of resources that you’re applying. Tell us a little bit about the sort of the process and how you got here, because this didn’t happen overnight. You must have sort of built this. What were the things that you learned along the way that helped you sort of build this to where it is now.
Dave Hunt
So I you know, It starts with it’s interesting. The individuals that we work with the these older adults, they go into the the exam rooms, and they say, you know, they start talking to the provider about our care teams, and I’ve heard from providers that our staff ends up knowing more about their patient population than they do. And they don’t see that as a bad thing, actually, they see it as a positive. And so what we learned early on is that, you know, you have to get somebody comfortable with just delivering the basics first. And as that loyalty and trust builds up with the care team, and with the technology, they begin to open up more and more, you know, so by no means we’ve made some, some blunders early on. And, and, you know, we learned a lot from those. And that as we go forward, what we see is that, you know, patients have to see the value in what you’re delivering. And that value comes across from everything that you’re you’re sending out to them. So the information we mailed them, we talked, you know a lot about the training that we give our caregivers, right. So right down to training on empathy, right? Because we’re leveraging depending on where how somebody grew up in their environment, they react to different situations differently, right. So some people are not comfortable talking about money. Some people are, you know, not comfortable talking about illness, right. And so we’ve spent a lot of time doing role plays with our care staff, talking about this environment, making sure that you understand, what’s the what’s the reality of this older adult, don’t be scripted, right, go off script, if you hear something, you know, change. And so those are the things that we’re learning. And so the trust factor grows, right, as that trust factor grows, they start to say, I’m more comfortable with using the voice bot, I’m more comfortable with trying the blood pressure, knowing that you’re going to be looking at it right away, right, I’m more comfortable relying on you to get me a ride over to my neurologist to the cardiologist I’m comfortable with you call me 24 hours before my appointment to make sure I show up. Right? And so that’s what we’ve learned over time here is that engagement really does matter. Right? It, you know, if you think about it, many of these older adults are isolated, you know, they do not have the support mechanism in aging is not easy at all. So, I mean, I’ve coming from it, you know, for siblings, so my parents had five children, they’re in Boston, you know, by all accounts, a phenomenal Health Care Center, and worldwide, it’s an outstanding healthcare institutions, rate insurance, to professional careers. So the finances to get additional support children that want to get involved, you know, thankfully, three sisters, you know, nothing my brother and I don’t do what we can, but I’m staying away right now. Right. So it’s difficult to do. And so you would look at that you say that is perfect setting for somebody to age, and yet it is still incredibly difficult. You know, and mothers, you know, you just see what has happened. And it’s just a challenge. And so now, if you put them in the top 5% of people that have everything going for them, and the aging process, and it’s still difficult, progressively you get worse, right? And you get down to that group that has none of those elements, right, maybe they’re living in a rural area that doesn’t have access to same amount of access to health care, right? Their children have all moved away. Right? spouse has passed away, right? They want to age in place. So people want to live in their homes, right? They you know, do they want to go to assisted living great, but it’s expensive, right? Do they, but they want to be around their friends that want to be around their family, the environment that they know, the pictures on their wall, right? That is where they’re comfortable with. And so we have to as a, as a group, continuously think about how do we help that group age, and that’s what we’ve learned, right is make sure we understand what’s important to the individual. And that’s going to vary by individual, and then deliver that in from that, when they’re comfortable, start to bolt on what’s going to give us the clinical insights, to actually have a meaningful change on their environment, and help them age successful. And that’s really what we’re learning and we continue to learn, right? We have a lot of learning to do. We’re seeing across a significant patient population, right? And so we get the benefit of learning. But I think virtual assisted living is going to be something that we’re going to be capable of right. I know that I have a gentleman in Louisiana who’s living with the spouse with dementia, and I have seen, you know, dozens and dozens and hundreds of other people in similar situation. How do I bring those together? Those folks together virtually right? I know that I have 10,000 people that we work with on a monthly basis that have COPD. How do I kind of connect those folks, right? So this virtual environment to me is something that is really going to help us and how do we help educate the family caregivers to become kind of a an extension of us and an extension of the provider? So I just think we’re We’re learning a tremendous amount, we’re going to continue to learn a lot. It’s really excited about where we’re going with it.
Nick van Terheyden
So, all of this, you know, has been in process and development for years to this point, I have to believe that COVID just sort of amplified, it made it harder. What was your experience through that unfolding?
Dave Hunt
Yeah, I mean, it’s tough to say that there’s a silver lining and COVID. But I’m sure 176 team members would tell you that, you know, our growth is has a lot to do with it, right? It’s put, it’s put staffing challenges on our providers, right, you had folks that were their children being homeschooled. And in providers, the brick and mortar environment was not prepared to go virtual, right. And they did a great job doing it, but it just wasn’t something that they were ready for. And so we’ve really been that virtual office for a lot of providers. And I think it’s put the fast forward button on it, right. And so, you know, virtual care was coming, no matter what, right. But it was probably 710 years of gradual development. And so we, you know, took that leap into a year. Right, so that was just like, a year or two of what we probably would have seen over the seven to 10 years. And so for Kasan, it’s been a, you know, a phenomenal boom, you know, we’re not going to go back at this point, if you look at a lot of the different programs that are coming out from from CMS, and a lot of the other programs that are out there, they’re all geared towards virtual care, if you look at a lot of the startup environment, a lot of delivery in the home. And so we just see a continued progression of this. And, you know, COVID, a, you know, clearly a very difficult time and in all of our lives, but for Khasan. And for the virtual care in the way that we’re delivering, I think it’s actually been excellent. And I think it’s actually good for the older adults. And when you think about the amount of the folks that didn’t make doctor’s appointments, that wouldn’t schedule them to begin with, that weren’t getting the care that they needed, just because you know, they were in difficult spaces, or they didn’t have the support mechanism, we’re now able to kind of break down the barrier of health care delivery, regardless of where you live. And regardless of what you’d have available to you, we can kind of deliver that virtual care is the equalizer, right? We really can deliver the same thing to every single older adult, regardless of where you live, regardless of your economics or your support mechanisms. There’s no difference for us virtual care is the same for everybody.
Nick van Terheyden
So I, you know, I think I’m with you, when you talk about that silver lining, it feels a little bit awkward because of what unfolded, but it really has, you know, virtual care, like many of these innovations, has been two years away for the last 10 years. And it was still two years away, right up until that point, and we sort of accelerated it. What’s left? And what are you excited about in terms of innovation in the future.
Dave Hunt
So like a patient reported outcomes is fascinating to me. So you know, we know, you fell, we know that we sent physical therapy in there, we know that the provider change your medication. So now we can train our teams and our voice bots to reach out to and say, How’s Nick, the physical therapist doing how your exercise coming? How’s that new medication and have the patient report back to us. So I see patient reported outcomes as significant. More in home delivery. More, you know, where, you know, we’re tracking, medication changes, we’re doing a lot more in that environment, a lot more around telehealth on the mental health side. So I think we’re just going to continue to really get patients in an environment where they have access at their fingertips for support, regardless of what they need, right. And so whether it’s nutrition, social determinants, whether it’s, you know, getting in touch with their provider and having a telehealth visit done, or getting a ride into the provider’s office, or into an you know, a specialist, that’s where we’re really moving towards, and I’m excited about that, because we can, we can deliver a cross functional clinical team environment support mechanism to these older adults, regardless of where they live. And that that, to me is a great, great future for organizations like ours, and for those that are looking for that care.
Nick van Terheyden
Fantastic, exciting times, you know, tremendous contribution to a burgeoning problem accelerated by, you know, the pandemic, I think, in a good way that sort of enabled some of this, I think made it more acceptable in many instances, you know, and lots of potential it certainly, as I listened to it, I go, Well, you know, the point that I’m looking for For those kinds of supporting services, that’s definitely the kind of things that I want because, you know, we’re we’re, it’s an inevitability of life as we all know and approach although, you know when you’re young you say, but that’s never gonna happen. Anyway, as usual, unfortunately, we’ve run out of time just remains for me to thank you for joining me. It’s been a fascinating conversation and an exciting time. David, thanks for joining me.
Dave Hunt
Doctor. Thank you for the time today really enjoyed the discussion and look forward to talking to you again
