The GRO Files: Field Notes from Hawaii to Manhattan 

Stephanie (0:00 - 0:16)
COVID and the years coming out of COVID with the talent war, now it’s the data war. Who can best mobilize data and their teams to effectively attack market share, effectively build those moats around their market? Who’s doing that best is really who’s going to win.

Tony (0:19 - 3:21)
Welcome to the endless summer edition of the Transcending Home Care podcast. My name is Tony Kudner. I’m the Chief Strategy Officer here at Transcend Strategy Group.

And it’s wonderful to be with you all. We’ve had a couple podcasts recently, but things at Transcend have also been, gosh, just a little bit busy. And we haven’t had time to record a kind of a bonus episode in a while.

And what has been keeping us busy here at Transcend is a proprietary diagnostic that we do called the GRO Assessment, which I think some of our listeners probably know, but it examines a lot of facets about what makes a home-based care organization tick, and what are the barriers to growth within the organization and the opportunities to unlock that growth in the name of mission-driven sustainability. My colleague, Courtney and I, and Allison and some others from our team, and Stephanie, we have been as far west as Hawaii and as far east as New York City doing these and several places in between with actually a couple more on the horizon.

And we don’t want to talk about them just for talking about them’s sake. We thought we’d maybe do a little tracking and trending of some of the things that we’re seeing out in the community. Because we know folks are always looking to constantly improve, and folks on the growth teams, whether you’re overseeing admissions or you’re overseeing the business development or community education function, we know you’re always looking for a leg up.

And so, we’re not going to name names, we’re not going to say who we’ve been out there analyzing, but we are thankful that we do get the privilege of being given access to so many different real-world challenges that people are solving in incredibly creative ways. And so just as a quick overview, the GRO™ Assessment, GRO is an acronym, G-R-O, that stands for Growth Readiness Opportunities. And it looks at a hospice or a home-based care organization’s entire operating model through the lens of four major areas that have a total of about 38 to 41, depending on the type of provider, attributes of things that Transcend has noted in our 20-plus years of existence as being critical for growth, one way or the other.

The four big buckets are financial readiness, competitive readiness, organizational alignment, and meaningful differentiation. And I want to have a discussion about those, and I can’t think of anyone better to have that discussion with than Courtney Penn, who is our COO, and Stephanie Johnston, who is the president and CEO and owner of Transcend, and the architect, the founding architect of the GRO Assessment. So first, Courtney and Stephanie, welcome to the podcast.

How are you doing this afternoon?

Courtney (3:22 - 3:23)
Thanks, Tony. Doing well. Can’t complain. 

Stephanie (3:23 - 3:28)
Always great to spend a little time with my colleagues. I enjoy it.

Tony (3:29 - 3:41)
Good. Yeah. We’re recording this on a Friday, and candidly, it’s the last thing I think standing between all of us and it being 5:00 somewhere, shall we say. If Courtney and Stephanie give two-word answers, that’s why I’m throwing them under the bus.

Courtney (3:43 - 3:44)
We’ll try to do you better than that. 

Stephanie (3:45-3:48)
Anybody who knows me knows there are no two-word answers.

Tony (3:49 - 4:40)
We are consultants. Yeah. So Courtney, I think I want to start with you and talk a little bit about competitive readiness.

You are, within our organization, you are the subject matter expert when it comes to admissions optimization. You’ve spoken on this at many national and state conferences, and you’ve authored some reports for us. Competitive readiness doesn’t live entirely in admissions, but it overlaps with it quite a bit.

So what are some of the things you’ve seen change most in that competitive readiness around referral dynamics, new market entrance, but also how competitors are showing up and maybe boxing folks out in some ways? What are some of the things that you’ve seen there that have changed since some of our earlier GRO Assessments?

Courtney (4:41 - 6:59)
Yeah, that’s a really great point. And honestly, one of the main things we’re even called for is, how do we compete more assertively and aggressively in our markets, where previously maybe we didn’t have to. The pace of change, I would say, has accelerated dramatically, especially in environments that are not used to having several competitors knocking at their doorstep.

A few years ago, most organizations could rely on their reputation and a long-standing referral relationship to help maintain that growth. And that’s just becoming really way harder than it used to be. And so we’re seeing increased market consolidation with more sophisticated competitors, a much greater focus on speed and responsiveness and access to care and providers who are prioritizing that.

And referral sources have more options than they ever have. They’re making decisions faster. We heard several times in our most recent GRO that referral sources are just throwing the referral up and seeing who can catch them. That is the reality that our clients and hospice organizations are facing. Organizations that rely on anecdotal market intelligence or assumptions about their competitive position are getting caught off guard. 

The other change is that growth is becoming more intentional, right? The organizations who are gaining market share tend to have stronger CRM utilization, for example, or better data and referral analytics, clearer strategic plans with owners and deadlines and, you know, expectations around those. So what used to be the relationship-driven growth model is increasingly becoming intelligence-driven growth. And it requires leadership that understands those things that can drive their teams to compete for their mission, certainly, but have a greater awareness of the competitive factors that are influencing your market conditions.

So that’s a significant shift. And many mission-driven organizations, I would say, are still adapting to it. But that’s one of the ways that we can help. And we’re very glad we can do that.

Tony (7:00 - 7:54)
One thing I might add that we see, you’re talking a lot about data-driven decision-making. Courtney and I were on a call earlier today with a client who it took them a lot of work and a lot of blood, sweat and tears, but they finally have a more or less real-time dashboard that gives them conversion rates down to the admission nurse level. And that’s not easy, especially if you’re a smaller organization, if you don’t have a robust data infrastructure behind you, that feels just insurmountable.

But it’s that level of understanding what affects your ability to admit patients that is increasingly becoming table stakes. And those are the types of things we’re seeing in the GRO. Stephanie, do you want to add something there?

Stephanie (7:55 - 8:14)
I would add that, I think you guys have nailed it, that COVID and the years coming out of COVID were the talent war. Now it’s the data war. Who can best mobilize data and their teams to effectively attack market share, effectively build those moats around their market? Who’s doing that best is really who’s going to win.

Tony (8:15 - 8:37)
Yeah. Steph, staying with you, I said them a little bit out of order. I asked Courtney a question about competitive readiness, but I know that financial readiness is the foundational bucket to the GRO Assessment.

Can you talk about when you were starting to design version one of this and iterate why that is?

Stephanie (8:37 - 10:11)
Great question, Tony, because you’re right, foundational readiness is the underpinning of it all. And what we’ve seen over the period of time from when we first started doing this to today is just like hospice patients are coming more acute, sicker hospice patients being referred later, we’re seeing the same thing with our client base, with prospects that are coming to us. I’m not saying they’re in dire straits or desperate. What I am saying is they’re feeling more financial pain from business performance than they had previously. Previously, when we first got our start, we’re doing a lot of work around branding and marketing, which are by nature growth oriented. Very seldom is somebody rebranding from a state of urgency. They’re usually doing that from a state of repositioning for the future. And it’s aligned with strategic planning, maybe a succession change in the C-suite. But the work that we’re doing now has us in more acute spaces when it comes to business health and business readiness.

And an organization often requires more work to turn it around, whether that’s in the data and analytics space that we talked about previously, whether that’s in people and talent development that we have to work on, or whether that’s in process redesign and optimization. It’s going to take a little longer. It’s going to cost you more because you’ve got more infrastructure in place than maybe you’ve previously considered.

So that level of acuity is something that we have to take care of first, because if an organization isn’t healthy enough to survive the journey, why put the patient through the curative treatment if they aren’t healthy enough to survive the journey? So that’s got to be table stakes first and foremost.

Tony (10:13 - 10:21)
A harsh reality in some ways, but you had an old COO who said to me one time, you can’t cut your way to growth.

Stephanie (10:22 - 10:26)
One of my favorite sayings from corporate America, I can’t cut your way to growth.

Tony (10:26 - 13:34)
Yeah, exactly. So I’m going to take on, I’m going to ask myself a question around meaningful differentiation, because I think this is one where a lot of organizations could act with a little more intentionality. And we’re seeing that in a lot of our client engagement.

So meaningful differentiation, as the name suggests, is what is the unique value proposition that you offer that nobody else in your market does? And I think when we ask this question often, when we do a GRO Assessment, we’re usually interviewing somewhere between 25 and 50 people on-site, depending on how large the organization is. We’re asking secretaries, God bless them. Thank you for answering the phones, through middle management, through members of the IDT, through the C-suite. And we ask this information because it tells us a lot. It tells us, is the value proposition for the organization known globally? Is it the same? Is it coherent? And the number of times we say, what would you say is the value proposition for your home-based care organization?

And what we get back is sometimes it’s a tax status, or sometimes it’s simply a listing of what the federal, the CMS, or whoever the ultimate payer is, expects as a part of that care, right? So if it’s a hospice, we’ll get answers back, like, we have nurses and an interdisciplinary team, and we deliver DME, and we’ve got good quality scores. The quality scores are a good place to start. But if you mention tax status, or the basic things that hospice or home health or personal care is supposed to provide as your differentiators, why should anybody choose you? There has to be, and I believe we’ve got an upcoming blog article that our colleague Alex wrote that talks a little bit about this, but a differentiated position in the market is not that we care. And it’s not, we’re a nonprofit that’s been here for a long time.

You need to dig several levels deeper than that into things like, what is our response time when a call comes in? What types of patients can we care for incredibly well that our competition does not? What ancillary service offerings like music therapy or Reiki do we offer, again, that our competition does not?

Because if you offer music therapy but so do three other providers in your service area, guess what? It’s not the decision-making factor. It’s not what’s different about you. And we encourage folks to not only think about those things, but to codify them and train staff at different levels of the organization to be singing from the same playbook. That’s where a truly meaningful differentiation is born within an organization. Stephanie, I see you want to jump in.

Stephanie (13:35 - 13:58)
I want to, I actually want to ask you a question on that because I wonder, are you seeing, when you hear those things back from clients, providers about the way in which they describe their competitive advantage and meaningful differentiation, do you think that’s because they’re more comfortable, more familiar talking about it with prospective nurses? Is that kind of the go-tos about how this work environment is different?

Tony (14:00 - 14:48)
I don’t. Courtney, I’d also be willing to hear your take on that. But I think running a growing home-based care organization is hard. I think marketing and value propositions are still very, they’re in their adolescence within the home-based care community because competition hasn’t been that fierce for a very long time. And so, nobody’s had to do it. If you’re the only provider that served your area, or there’s only been one or two, and there’s sort of gentlemen’s agreements about you have your facilities that you care in and I have mine, it’s not a muscle that’s ever been needed. And then people have deployed the resources and the capital elsewhere. I think that’s no longer true. Courtney?

Courtney (14:50 - 15:59)
One example that comes to mind from a GRO we did this year was a provider who said they can be at the bedside within 30 minutes of referral, anywhere in their service area. That is a guarantee that they stand by, that they feel confident in, but that wasn’t articulated in any of their materials. It’s not the first thing that we heard when we were asking about what their differentiators are? What was their value proposition in the market? So, I think the default position is often we’re a nonprofit or we care, or we have these ancillary programs. Because there hasn’t yet been a concerted effort to really define those differentiators, to articulate them and train and educate teams on how to talk about those things in the market. If you have a promise like that, I think the three of us and everyone listening would agree, whoa, that is gold. And I think they had 17 or so competitors in their area. That’s very powerful. And it’s just about how do we ensure that everyone within earshot understands that about us.

Stephanie (16:00 - 16:52)
That is phenomenal. When I think about being a family caregiver, which several of us are in our everyday lives, I think of how potent that is to say, you don’t have to wait overnight for help to come. And it’s an incredible, meaningful differentiator.

So another question I would just ask, if you don’t mind me asking a couple questions here, love to hear your takes on these things. So we talked about the staff kind of writ large, but thinking about the role, particularly of business development or liaison and the training and development that’s required for that, because that’s multiple layers deep, right? It’s not only this organization and what makes it different.

In some instances, you’re educating around the fundamentals of the hospice benefit. You’re educating about how business development and clinical services work together. Talk a little bit about the experiences that you’ve had in that space through GRO.

Tony (16:54 - 18:52)
Wait, this is now going to be like a Ken Burns documentary-length podcast, Steph. So as it relates to training for those folks, Courtney, maybe I’ll ask you to speak a little bit more on the admission side. For the business development side, as a part of our GROs, I go on multiple ride-alongs in the field on any GRO that we do.

So I’m with the person, whether you call them a hospice care consultant, a liaison, a provider services executive, whatever your name for that function is, I spend half a day to three-quarters of a day. And these folks to a person are all hungry to learn and struggle to find education. Selling anything is hard, but very few playbooks for business development exist out in the marketplace. And they’re often led by folks who, no fault of their own, but maybe have multiple portfolios. If it’s a smaller organization, maybe that person is the director of business development and marketing. And so they’re trying to do that. And if it’s a nonprofit, maybe they’re the director of business development, marketing, and fundraising and philanthropy. And that’s been a consistent through line in a lot of the GROs is how do we quickly bring that up to maturity? And then from a messaging standpoint, also being intentional, right?

Here are the key messages that any external stakeholders should know about us. And business development here is the subset that applies to the people you’ll be interacting with every day, whether that’s patients and families or referral sources or other community professionals. So I think those are the two ways and the two things I see the most often is the hunger for that. Transcend’s working on one or two things in the background to address that. But Courtney, on your side from the admissions and intake team, what are your thoughts?

Courtney (18:53 - 20:44)
I think just across the providers we’ve been able to assess, I think it’s similar in the access and admissions arena. Every program handles that differently. There’s variability in leadership structure. Is the admissions department led by an RN or more of an operations-minded person with RN supervision at the ready? Are access coordinators virtual or are they all in a pit environment where they can coach one another and talk in real time? And so taking into account the variability of how that critical function is handled or that critical, I think we refer to it as an organism this week because it truly is, it warrants very customized assessment, which is part of what the GRO does, but also recommendations.

So I think what I find rewarding in this work is being able to map the referral to admission journey for organizations and point that back to them and say, here’s where you’re spending too much time. Here is where your bottlenecks are. Here is where you could gain some efficiency.

And more often than not, the executives, the folks in leadership who are worried about all the things are very surprised to learn those things. And it’s really, like I said, rewarding to be able to point out some of those challenges and recommend ways to overcome them. Sometimes it’s a simple fix. Sometimes it’s more challenging. It’s always nuanced though. And that’s why a nuanced approach is really appropriate in both business development and access and admissions because similar to palliative care programs, they’re all different and every organization is different. Every market is different. So you got to approach it from a customized standpoint.

Stephanie (20:46 - 20:51)
Along those lines, can I ask another follow-up? I’m not trying to hijack and turn the tables on Tony.

Tony (20:51 - 20:53)
Said the CEO/owner of the firm.

Stephanie (20:55 - 22:07)
It’s not at all a control freak periodically, never shows up that way to type A. But I think there’s something really interesting in some of the challenges that you all are able to step into in this space, because it is one part this data-driven assessment that you do, this process-oriented assessment, that you also are able to overcome a lot of fear. And I don’t know how many of these conversations we’ve had before we started GRO where a CEO expresses some concern over, but will you really get my people to talk? Will you really get honest answers? And I love hearing that question and then seeing it on the other side of the GRO, seeing that same CEO say on the other side, I can’t believe you’ve got that level of detail and that level of honesty in two or three days on-site when I’ve been thinking about it and wrestling with it and losing sleep for months. Could you talk a little bit about that and also talk about the vulnerability that can go along with having someone come in? Because you’re not the two Bobs from Office Space that are going to come in and say, what is it you would say you do around here? Can you talk a little bit about how you set people at ease and how you get the honest answer?

Tony (22:09 - 23:51)
I’m happy to jump in on that. I think that’s where being former operators is just crucial, where I love throwing the big four under the bus and saying, we’re not Deloitte, we’re not KPMG, we’re not going to send some 23-year-old MBA out to your program to ask a stock list of questions. I don’t think that works.

And when I was in big corporate and we had organization that shall remain nameless, but their acronym is BCG come in, and it was that, it was like, what would you say you do here? So first of all, you’re going to assess the efficacy of how I do my job, but first you’re going to ask me to teach it to you? Get out of here. My guard was immediately up. We use a lot of nuanced tells, will drop language and acronyms that immediately suggest to folks that we understand your world, not in an authoritative put them on their back heels, but knowing what an IDG is or knowing what a start of care is and being able to just disarmingly ask in their vernacular. I think that helps a lot. And then we’re also, I don’t speak for you, Courtney, but we’re like, we’re teddy bears. We’re not, I don’t wear a suit. I don’t put my chair up higher so I’m sitting down looking at them. It’s informal and we’re friendly folks. And folks usually honestly find themselves wanting to talk and share their experiences when they find they’ve got someone truly listening to them.

Courtney (23:52 - 24:46)
I would add to that; there’s a lot of intention that goes into the preparation before the visit. We help leaders communicate who we are and why we’re there and maybe the types of questions we’ll be asking. The level of preparation is dependent on comfortability of staff within a particular organization we’re working with, but also the preparation that goes into the types of questions we’re asking. We’re analyzing data before we even get there. So we want to be very mindful of the time we’re asking people to spend with us. We want to get right to the issue. There are consistent sort of through-line questions that we ask as well to test for consistency and answers, etc. But really by the end of every GRO, everybody just takes a big sigh of relief and they’re like, that really wasn’t as hard as I thought it was going to be. So that’s really fun.

Stephanie (24:46 - 24:54)
I remember somebody saying that they wish that there was a note on that door when they were going out that said, see, that wasn’t so bad or something like that.

Courtney (24:55 - 25:17)
To be disarming like teddy bears. We’re not there to scrutinize anyone’s job. We really want to understand the world in which they live and work at that organization as best we can in 48 to 72 hours. And getting that breadth of perspectives is the best way to do that.

Tony (25:17 - 25:49)
100%. I think we disarm folks. Yeah, I think we are disarming, but I also do want to say that there are times when it’s clear that somebody isn’t in the right seat on the bus. And we don’t shy away from that if, ultimately, it’s what’s best for the mission of the organization. And candidly, that individual, nobody likes not being good at their job, I don’t think, but there’s a way to, as Leo McGarry from The West Wing used to say, there’s a way to be a guy.

Steph, what did you want to say?

Stephanie (25:50 - 27:03)
I can’t speak to the way to be a guy, but I know what you mean though. I also think this, Tony, is another area where you and Allison and other members of our team coming from the provider experience, you not only understand the language, you understand the culture that it takes to successfully operate one of these organizations. You understand the teams that it takes in place. And the last thing you want to do is leave an organization worse than you found it, where you’ve damaged relationships as a result of this process in some way. So I think that kind of candor and GRO, the origins of GRO do come in part from the best practices of consulting for our own, from my own experience being inside of Fortune 500 and being an in-house consultant in some spaces and stepping into a manufacturing plant and trying to tell a 60-year-old plant manager how to run his plant when I didn’t have the experience in plant operations. That’s a space that nobody really wants to be in on either side of that equation. So having the experts who also just embody the values of our firm and the values of the industry are just so incredibly important.

Tony (27:04 - 28:02)
Yeah. Honestly, I think we could keep going on and on, but this is already close to the upper limit for how long Transcend likes to keep our podcast, just long enough so you can listen to it when you’re driving from a Genesis facility on the west side of town to a Care Initiatives facility on the north side. Shout out to Iowa.

But we always close these with a little moment of levity where we list some pet peeves. And I’d love for you guys to list one airing of the grievances for something that’s frustrated you. I can go first.

I took a train trip home from a recent GRO and there were tons of open seats on the train, right? And somebody sat next to me, and I’m like, what are you doing? There’s still double seats open. And the guy goes, can I sit here? And what do you say? But come on, there’s a way to be a person. You know what I’m saying?

Courtney (28:04 - 28:09)
Totally. Yeah. I get that way with parking spots.

I’m way out here. Why are you parking next to me?

Courtney (28:12 – 28:13)
Steph, you want to share yours next? 

Stephanie (28:14 - 28:19)
No, I was just going to say parking spots and parking in the spot. In the spot. There are clearly delineated lines. 

Courtney (28:19 - 28:20)
Get in the spot. One job.

Stephanie (28:21 - 28:29)
The trucks at the airport. That’s my pet peeve. Trucks at the airport, taking up two parking spaces. Park somewhere else. 

Courtney (28:31 – 29:08)
The cyber trucks, especially. 

Well, one I have, we were at a restaurant this week in Manhattan. Beautiful outdoor seating and the temperature was nice. So we were like, let’s sit upstairs near the balcony. And I kid you not, I think a staff member walked by us for a good, what, 30, 40 minutes before taking our order or something like that, Tony. So as a prior, someone who has worked in the hospitality industry, it just grinds my gears. So anyway, we were having a good conversation, so it was okay. Anyway, that’s my pet peeve.

Tony (29:09 - 29:52)
Yes. This is what people tune in for. I get more emails about the pet peeves than I do about the content.

Thank you, guys. Thank you, individuals, so much for joining us today. And thanks to our listeners. We’ve got some other podcasts coming up that I’m actually set to record in the next couple of weeks. One on sales liaison accountability and how to handle that, especially if it’s not something you’re used to or comfortable with. So I’m really excited about that one. And I know we’ve also got some maybe in the pipeline about some secret shopping, which is something that can help you create a differentiated position in the market. So stay tuned. And Steph and Courtney, thank you so much for joining us.

I always love these conversations.

Stephanie (29:54 - 29:56)
Thanks, Tony. Thanks for letting me hijack a little. 

Courtney (29:57)
Thank you.