Nicole Haney talks about a key strategy for growing her home care service line.
Nicole Haney was inspired to open an adult day center when her grandfather began struggling with Alzheimer's and her family had a difficult time finding consistent caregivers. "I couldn't set the expectation or the standard of the care that he was receiving, and so I just decided we're going to do the day center and he can come here, and we'll take care of him too," she said.
Haney is the owner of Papa's Place Adult Day Center in Reed City, Michigan, and is a featured speaker at the Decision Health Private Duty National Conference & Expo, November 12–14, 2023, in Las Vegas. Haney will speak on the topic of "Leadership Primer: Shift Your Mindset, Step Back, and Watch Your Agency Grow."
Haney recently talked with HealthLeaders about the growth strategy at Papa’s Place. Figuring out the services Papa’s Place could consistently provide was a key part of this strategy and as it maintained that consistency, its reputation and business benefited.
Papa's Place Adult Day Center opened its doors in 2018. Haney previously worked in administrative hospice roles, giving her the experience and knowledge of the post-acute sector, along with staffing and client management.
While her vision for Papa's Place didn't initially include home care, the COVID-19 pandemic forced the business to pivot, and the facility began offering limited home care services.
"We really had no choice but to transition into home care if we wanted to stay in business," Haney said. “We made a quick pivot and jumped into home care. That’s where the business took off.”
HealthLeaders: How did your clientele transition with you from the adult day center model to the home care model?
Haney: “Most of Papa's Place clients are based in Northern Michigan—a rural, low-income area. The majority of our referrals come from Medicaid waiver case managers—about 95%. At first, we had to figure out how to make Medicaid profitable, especially in this industry. There really is not, honestly, a huge private pay market for what we do in the 11 counties that we serve for home care. So, [we have] been being very strategic with our margins and understanding where our limitations lie. We didn't start off providing home care on the weekends because that's the hardest to staff. We still don't provide overnight care because we cannot consistently provide that. However, we serve between 50 and 60 home care clients per day.
We don’t have a huge marketing budget. We had to be strategic on what we could be consistent with, and by being consistent, we were able to build our reputation.
It literally made the difference for us. Everything that we've built has been organic. It's been about figuring out what our right fit is—what our right fit client is, and what our right fit staff is, because without those two, one area is going to lack if they're not both consistently monitored and nurtured.
It comes down to your organic message and your consistent ability, and if you make all the promises in the world and you can't follow through on them, then, in this industry, [people are] going to move on to the next one that's available to do that.”
HL: Has your consistency helped your relationships with not just your clients, but your caregivers as well?
Haney: “We're very transparent with our staff. We tell them as much as we want to be a right fit for our clients, we also want to be a right fit for them and a right fit for us.
That transparent communication starts from day one, and people will know before they walk in the door what their job is, what their pay scale is, what the expectation is.
I think that it can, and will, make the difference for other agencies on whether they get caregivers to apply and follow through with investing as an employee in their company because it really is about making sure that you have happy staff. Because without happy staff, they're not going to want to serve and provide consistent quality care to the clients.”
Hear more from Nicole Haney as she presents at the Decision Health Private Duty National Conference & Expo in November. Be sure to register for this event!
The report identified recruitment, workforce well-being, and advocacy as common struggles.
As the home care and home health markets continue to grow, agencies and franchises alike are struggling to keep up with the demand for services due to the caregiver and nurse shortage.
A recent industry report by the National Association for Home Care and Hospice called the shortage a "crisis," and offered actionable recommendations for leaders, providers, and agencies.
The report identified the following as common issues agencies struggle with:
Workforce well-being: The welfare of caregivers must be made a central part of the organization's culture.
Recruitment, training, and retention: Agencies must broaden their search for workers, commit to providing thorough onboarding and training, and show those with longer-term goals the career paths available to them.
Transparency and visibility: Members of the home care space must contribute and amplify the conversation around services and care that are able to be provided in the home, including raising awareness about affordability.
Policy and advocacy: Leaders in the home care space must also advocate for legislators to address funding, legislation to support family caregivers, Medicaid and Medicare rate increases, and immigration reform.
While the following are actions for the home care and home health sector to consider as a whole, the report states that these are also actions individual agencies can take:
Attracting and Retaining Caregivers
Instead of in-person trainings, the report recommends virtual training to make onboarding easier and faster.
Peer mentoring can be helpful for new hires in their first 90 days with an agency, reducing turnover.
Replace weekly or biweekly pay with daily or on-demand access to earned pay.
Education, Career Paths, and Elevating the Profession
Work with local nursing programs to support teaching and working in home-based care.
Promote the image of home-based care via social media.
Define and support career paths for home-based care and invest in resources to support career advancement.
Advocacy and Supporting Legislation
Oppose further Medicare rate cuts by the Centers for Medicare & Medicaid Services.
Support legislation like the Credit for Caring Act and Home Care for Seniors Act, advocate for the passage of the Better Care Better Jobs legislation to increase accessibility to home care services, and improve caregivers' wages.
Join the American Hospital Association and other healthcare provider groups to support the refiling and passage of a revised Health Care Workforce Resilience Act, which would create a path for immigrant nurses and physicians to access previously unused visas.
While the Biden administration has proposed a federal staffing mandate, New York state implemented theirs last year.
Staffing mandates have been touted as the answer to concerns about the quality of care provided in the nation's nursing homes. However, many facilities are unable to recruit sufficient staff to comply with the mandate.
While a federal staffing mandate has yet to be decided, some states have implemented staffing mandates of their own.
On January 1, 2022, the state of New York's staffing mandate went into effect requiring the following: a minimum daily average of 3.5 hours of nurse and certified nurse aide (CNA) care per resident per day (HPRD); a minimum of 2.2 HPRD provided by CNAs; and a minimum of 1.1 HPRD provided by a licensed practical nurse (LPN) or RN. The remaining 0.2 HPRD can be provided by an RN, LPN, or CNA.
"Member facilities have been struggling to hire staff prior to the pandemic because of New York state's low Medicaid rate," Jim Clyne, president of the New York chapter of LeadingAge, a community of nonprofit, mission-driven aging service providers, told HealthLeaders.
Until 2023, members have seen the Medicaid rate increase by only 1%, and that Medicaid pays for more than 72% of the days care is provided, he said.
Because of its low rates and Medicaid being such a large payer, which affect facilities’ ability to recruit and retain staff, member facilities are having to lower their occupancy. According to Clyne, there are currently 6,000 more unstaffed nursing home beds in New York than in 2019.
For the first quarter of 2022, Gov. Kathy Hochul waived penalties for facilities unable to maintain the necessary number of staff due to the workforce shortage, declaring it a healthcare staffing emergency. In April, with the declaration still in place, penalties began going into effect.
While the Department of Health has not released details on how penalties are assessed, they can be as much as $2,000 a day.
Staffing mandates have been criticized for their "one-size-fits-all" approach, and Clyne maintains that all nursing homes are not the same; that they have different staffing needs.
"A nursing home serving medically fragile children needs staffing that is completely different than one serving a geriatric population," he said. "Even with the geriatric population, ventilator-dependent residents are very different from dementia residents.
"Certainly, if the national mandate used additional staffing titles beyond the three nursing titles used in New York, there would be a greater recognition of the full range of services being provided to residents."
Devin Jopp discusses home health's current lack of lack of infection prevention oversight.
Editor's note: This is the second part of a two-part series. Read part one here.
HealthLeaders continues the conversation with Devin Jopp, CEO of the Association for Professionals in Infection Control and Epidemiology (APIC) about the need for infection control oversight in the home health setting.
As more individuals prefer to receive care in their home and older adults opt to age in place, home healthcare has seen substantial growth in the aftermath of the pandemic. Here is part two of HealthLeaders' interview with Jopp.
The following transcript has been edited for clarity and brevity.
HealthLeaders: How can we make infection prevention efforts a priority in healthcare overall?
Devin Jopp: We should be investing in our public health infrastructure. We should be building a pipeline for infection prevention and infection preventionist (IP) training and putting new infrastructure in place.
We should make sure we have surveillance systems in long-term care facilities, and IPs in long-term care facilities. All these pieces still aren't there, and I don't think there's the bandwidth politically to push some of these things, but we've got to dig deep and find the will to do the right thing and make these investments, because otherwise we're just going to be sitting ducks for the next infection, and it will come.
On the other hand, we're talking about pushing new models of care, like hospital at home or advancing home health. How are we going to do that when we can't even get the other components of what we're doing situated?
HL: How should healthcare professionals handle the gap in perspective when it comes to explaining these issues to legislators?
Jopp: The general politics of the acute-care and long-term-care lobby are very sophisticated. There's a lot of money in it, there's a lot of established players in it, so it's a lot harder for the home health organizations to get the same level of attention in the broader ecosystem.
There are education barriers around helping Congress understand that. We've got to educate legislators around that.
HL: It's been recommended that skilled nursing facilities have at least a full-time infection prevention officer on staff full-time. Would you recommend the same for home health agencies?
Jopp: APIC is coming up with a new staffing ratios calculator this year that's going to start by looking at different segments. Initially we will focus on acute, long-term care, and ambulatory, which looks at a whole bunch of resources and then determines what's the optimal number of infection preventionists you should have on staff.
We don't have one yet for home health, but we do have a white paper that will come out at the end of this year on infection prevention and control in home health, hospital, and hospice that will have some thoughts and ideas around what needs to happen in this space.
I think, if you are a home health agency, you absolutely need to have an infection preventionist on staff—at least one to help provide guidance. But after that, it depends how many homes you might have and how often people are doing rounding.
The Biden administration's proposed staffing mandate could cause more harm than good to struggling facilities.
Post-pandemic, the Biden administration has increased efforts to hold the nation's skilled nursing facilities (SNFs) accountable for the quality of care they provide. Such efforts have included potentially implementing a staffing mandate, which many facilities have been vocal in objecting.
In the letter, Mark Parkinson, president and CEO of AHCA/NCAL, acknowledged the impact the pandemic had on the healthcare sector and its workforce, as well as the need for improvements in the long-term care space.
"However," he added, "meaningful change will not happen through unrealistic requirements and enforcement, but through collaboration and innovation."
In the letter, available on the organization's website, AHCA/NCAL offer four policy proposals to help address the quality of care in nursing homes:
Publicly report customer satisfaction: Add a customer satisfaction measure to the Five-Star rating system and Care Compare data from the Centers for Medicare and Medicaid Services.
Build the long-term care workforce: Implement the efforts outlined in the Care for Our Seniors Act workforce proposal to supply, attract, and retain workers in long-term care by leveraging federal, state, and academic entities.
Improve the special focus facility program: Begin incorporating evidence-based performance improvement approaches designed to help the facility improve quality care of residents they serve and successfully graduate from the program.
Enhance CMS SNF value-based purchasing program: Add a measure about adopting systems of care related to high performance, as defined by the U.S. Department of Commerce Malcolm Baldridge Framework, which would drive systemic quality improvement.
"We understand that the original intent of proposing additional federal staffing requirements is to enhance care," Parkinson wrote. "However, given the current and forthcoming caregiver shortage, we do not believe a federal staffing mandate will be feasible nor will it yield the intended outcome of improving care."
While the demand for home health services grows, the lack of infection prevention oversight presents a problem.
Editor's Note: This story is part one of a two part series.
When HealthLeaders previously spoke with Devin Jopp, CEO of the Association for Professionals in Infection Control and Epidemiology (APIC), about the importance of infection prevention efforts after the public health emergency for COVID-19 ended, he emphasized the role infection prevention specialists play in any healthcare setting.
As more individuals prefer to receive care in their home and older adults opt to age in place, home healthcare has seen substantial growth in the aftermath of the pandemic. HealthLeaders spoke with Jopp again, reopening the conversation around infection prevention—this time focusing on home health.
The following transcript has been edited for clarity and brevity.
HealthLeaders: How should home health have implemented or developed processes for infection prevention?
Devin Jopp: It's already hard enough to maintain infection prevention efforts in a hospital or an ambulatory care center, but when we start thinking of it in regard to home health, we start making a lot of assumptions about these environments: they're all great homes that are safe, that they're cleaned, that they have access to what they need, that they actually have capable caregivers that can deliver the same kind of care.
Particularly with these hospital-at-home models, they're increasingly using virtual components—remote patient monitoring or even telehealth visits. The provider might never step foot in the house. They might get a tablet with the physician communicating through it.
In our world of infection prevention, the issue is that pathogens aren't virtual, so there still must be certain processes that go into prevention and response, and to make sure that we are keeping all of the patients safe.
It's challenging because it's not one-size-fits-all in this space.
HL: How would you suggest home health integrate infection prevention efforts/specialists into their operations?
Jopp: There's got to be a reinvestment into building some sort of remote and mobile teams that are managing these homes. We worry about how many nurses and infection preventionists we have, but we're going to have to worry about that in the patient's homes.
We're going to need infection prevention control specialists or individuals training in infection prevention control coming to the house, making sure that things are being done on a random basis. Maybe environmental services will have to be provided. Maybe there will be some housekeeping service that's provided to come and make sure that those rooms are cleaned.
What I hope will happen is that we're not just going to say, “We're scalping savings here off of this system,” but that we're going to reinvest that into a model that's going to help support the family and really help yield better outcomes.
Otherwise, it's just shifting the burden and ultimately the caregiver and the family is the one that pays the price.
HL: Should there be more accountability for hospital-at-home models since they have access to more funding than home health agencies?
Jopp: I think the jury's out. These hospital-at-home programs aren't necessarily tied to hospitals and we're seeing in some cases they can be physician groups that are, in essence, having patients referred to them.
To me, regardless of who's doing it, whether it's a physician group or a hospital, I think there absolutely needs to be accountability. But even with the home health organizations, there's room for more accountability there, too.
Our loved ones deserve to be safe no matter what environment they're in. The reality of it is that in the home environment, while there's some real benefit to it, there's also got to be oversight.
We've got to figure out ways where we're building processes on a similar model or at least a modified version that's ensuring that patients are staying safe in their homes.
The action plans address issues ranging from resident experience to staff wages and support.
Nursing homes have been under increased scrutiny in the aftermath of the pandemic, particularly regarding their conditions and the quality of care they provide. The Biden administration has made some efforts to address these issues, and most recently, the Moving Forward Nursing Home Quality Coalition has brought forward some suggestions.
Funded by the John A. Hartford Foundation and consisting of more than 120 individuals and organizations advocating for nursing home reform, the coalition has announced a series of action plans to improve nursing homes over the next 12 months. There are nine plans in total, outlining goals and steps to achieve them, as well as noting the partners and infrastructure that would be needed.
"These plans represent reforms that stakeholders can advance to create nursing homes in which lives are nurtured, residents are empowered, and where people want to work," Alice Bonner, PhD, RN, chair of the coalition, said in a statement.
"It's time for providers, policymakers, and advocates to pull the needed levers to achieve broad, sustainable change in nursing homes."
Over the past year, the coalition has worked with long-term care advocates, nursing home leaders and residents, policymakers at the state and federal level, and other advisors to develop action plans. These plans reflect the greatest needs and potential impact on resident quality of life:
Addressing residents' goals, preferences, and priorities
Strengthening resident councils
Improving wages and support for certified nursing assistants (CNAs)
Expanding CNA career pathways
Enhancing surveyor training on person-centered care
Designing a targeted nursing home recertification survey
Increasing transparency and accountability of ownership data
Developing a nursing home health information technology readiness guide
Financing new nursing home models that are smaller with private rooms
Many of the plans are already in progress, including the analysis of more than 10,000 older adults' preferences which will be used to inform the care planning tool to better assess progress toward care goals.
"These plans are long overdue—they are actionable and absolutely imperative declarations of what must happen to ensure quality and safety in the care of people in nursing homes," Terry Fulmer, PhD, RN, FAAN, president of the John A. Hartford Foundation, said in a statement.
"We need the nation to coalesce around these action plans and help make them a reality. Everyone should see themselves as a vital part of the solution to improve our country's nursing homes."
The coalition will also be hosting “Coalition Conversations” in upcoming months, providing more details about the action plans and ways other individuals and organizations can get involved.
The health system is poised to reach more patients looking to age in place comfortably.
OSF HealthCare, based in Peoria, Illinois, has begun the application process to bring the Program of All-Inclusive Care for the Elderly (PACE) to its patient population.
The program is anticipated to begin mid-2024, upon completion of the application process.
HealthLeaders spoke with Nathan Pritzker, the system's director of PACE strategy and operations, about the extensive application process, goals for the program, and how they plan to integrate the current resources within the system into the program.
The following transcript has been edited for brevity and clarity.
HealthLeaders: What types of resources and services does PACE offer?
Nathan Pritzker: Since we're programmed for all-inclusive care of the elderly, we cover all required care for elderly populations that is reimbursable by Medicare or Medicaid or that could be reasonably expected to keep a PACE participant healthy and aging in place with dignity.
We cover everything from drugs to assistive care in the home, to hospitalizations and surgeries, all the way to transportation and meals, if that's what the individual requires.
HL: What does the application process consist of?
Pritzker: The PACE application is very rigorous. We need, among other things, to complete a relatively significant listing of our policies, procedures, and protocols that surround the care and protection of elderly populations.
We needed to submit a detailed financial analysis and plan indicating our ability to support a pay center during a startup period, which can be relatively costly. We will undergo an extensive facility assessment to ensure our PACE center and supporting assets can facilitate the program.
We are working through the required process to put together a bid to administer the pharmaceutical needs of the PACE population. We are also working through a contracting and networking process to make sure that all major types of care, including specialists, are in network for our participants just like an insurance program would need to do so that we can refer any PACE participant and make sure that they can get the service they need in a timely fashion.
HL: How will the PACE Program benefit the area for which the OSF provides care?
Prtizker: We have been in the application process for a geography that coincides with the central Illinois area around the tri-county area around Peoria. It's a mix of rural, urban, and suburban areas, and it coincides well with our major areas of operation.
We'll have resources either employed directly by our PACE department or through our contracts internally with our own home health and home care divisions to make sure that we can deliver the full suite of in-home services that PACE participants need, leveraging as much of our existing infrastructure as possible.
HL: What are OSF's goals for the PACE program, upon the application's approval?
Pritzker: Our vision and our aspiration for PACE is to better care for our aging population in the homes and communities they're in. We as an organization have a mission to serve with the greatest care and love and meet people where they are. PACE allows us to do that without concern for the walls of our hospitals and with a much greater degree of flexibility in the modalities of care that we use.
The PACE program is quite beautiful in that it allows program participants or PACE organizations to have significant flexibilities in how they deliver care and how we're no longer bound by the same fee-for-service constraints.
We are able to take a much more proactive population health approach for an often-high-needs group of people that tends to slip through the cracks.
HL: The program will also include the establishment of an adult day center. What will the facility's role be?
Prtizker: All PACE programs revolve around a PACE Adult Day Center that acts as the hub of care for PACE participants.
Partipants can come to the center and experience social activities, group events, entertainment, and receive care they need. Attached to our proposed site is a clinic and rehab facility, and PACE programs are also required to provide transportation and meals for their participants, at least in the adult day center setting.
OSF is very fortunate to have a longstanding adult day center in the Peoria community, which we are retrofitting to become our PACE center. We plan on building on to that model to better serve and provide more services to that population and any members of our adult day center population that may want to enroll in PACE once our application is completed.
The program serves to monitor patients' chronic conditions and enable them to take control of their health.
In the early days of the pandemic, Vanderbilt University Medical Center in Nashville, Tennessee, set up a COVID-to-home program to prevent capacity issues for the hospital.
While it initially served to streamline care for patients in different care settings, it has developed into a chronic disease monitoring program for Vanderbilt Home Care Services.
"When COVID numbers were thankfully starting to decline, we recognized that there were components of that program which were very beneficial to patients," Tara Horr, chief medical advisor for Vanderbilt Home Care, told HealthLeaders. "And so, we looked to adapt some of the roles from that program to carry forward and apply to other patient populations.
The program, which started in February 2022, serves between 50 and 60 patients a month, 35 patients at a time, with a total home healthcare census of 600 to 800 patients, according to Kristina Niehoff, Vanderbilt Home Care's pharmacist.
"Our two most common conditions that we [see] right now are heart failure and diabetes, with COPD being the third," she said.
The program's structure is simple, with staff communicating with patients via telephone to monitor their conditions.
"We think that it is beneficial to provide patients with a type of monitoring that can be ongoing and so we aim to look at the types of supplies that patients have in their home that allow them long-standing ability to monitor their disease," Horr said.
Vanderbilt Home Care uses scales, blood pressure cuffs, and oximeters and teaches patients how to use them. By relying on phone calls, Vanderbilt is able to reach a broader patient population, Horr said.
"We also ensure that the patients know how to record their values. If there's low or high blood pressure, we can ask further questions to help the patient learn what symptoms to watch out for," Niehoff said.
"It's a more hands-on approach to education and shows the patients how to manage their chronic conditions at home."
The increased contact with patients and emphasis on educating them also helps guide the Vanderbilt Home Care team's use of other resources within the health system.
"We make sure they know what to do and who to go to, so that if they see a value that is outside of the norm for them, they know how to reach someone to address that concern," Horr said. "And thereby, hopefully, decrease the number of urgent care and emergency room visits."
With the ongoing workforce shortage, the program also enables staff to maintain regular communication with patients.
"We can see that sometimes patients are at risk for readmission and that period of being discharged from the hospital is a very vulnerable time, and so this can allow us to make contact with the patient sooner," Horr said.
After a career in technology consulting, Dadong Wan has found a greater sense of purpose as a franchise partner.
In a previous story, HealthLeaders reported on the growth that Seniors Helping Seniors, a home care franchise, has experience so far this year. The key to this growth has been finding potential partners who are passionate and energized to deliver high-quality care to seniors, according to Dave Wagner, franchise consultant.
HealthLeaders spoke with one such franchise partner, Dadong Wan, about his experience entering the home care sector thus far and the process for becoming a franchise partner for Seniors Helping Seniors.
The following transcript has been edited for brevity and clarity.
HealthLeaders: What drew you to home health care, specifically Seniors Helping Seniors?
Dadong Wan: I had a family situation where I had to take care of a relative. I went through the process of finding a caregiver for them, while I moved from Chicago to Dallas, and it turned out to be a pretty challenging situation.
Also, I did a project for my previous employer where I looked at aging in place. I know the general trend and demographics with baby boomers and how our healthcare system is ill prepared for this—the silver tsunami. There's just a huge increase of demand.
I wanted to move away from technology, really focusing on human connections and just happened to be working with a business coach. I shared with him what I was looking for and the project I did, and he said, "Well, have you heard of Seniors Helping Seniors?"
I thought that the name sounded interesting, and then he recounted the story about our founder and that just blew me away. I'd love to be part of a community that is compassionate and caring about the most vulnerable part of our population.
HL: When did you open your location?
Wan: I signed the contract at the end of January and it took me about three to four weeks for me to get a state license from the state of Texas. I got it in early March and then began ownership training. I was ready to hire caregivers in April, and I just signed a third client.
HL: How many caregivers do you have on staff?
Wan: I have around 15 or so caregivers. I'm very happy about where we are. Most are seniors themselves, retired teachers and nurses.
Since it's "seniors helping seniors," meaning that we are hiring seniors, most of them are retired themselves. If we look at the demographics, as an industry, homecare has shortages because they're looking for younger caregivers and they are in short supply.
But if you look at people who are near the retirement age, they are underemployed and they are the ones who have time.
HL: What was the process for joining the franchise?
Wan: Once I decided on Seniors Helping Seniors, my business coach directed me to a marketing company that represents it and other franchises. There was a process called “discovery,” where I had multiple calls with existing franchise partners and some of their management team to understand their business model.
It took about a month to give me insight into the business, and then if I felt comfortable I'd sign the franchise agreement. From that point onward I just had to go through the state business licensing process.
That's the beauty of the franchise system. They have the formula, which has been proven to work, so we don't have to reinvent the wheel.
HL: How often do you communicate with corporate now that your location is up and running?
Wan: We get assigned a coach from the corporate level. Every week we have a session where I can get guidance, advice about what needs to be done and how to course correct. There are different things we see while working, so the corporate coach makes sure that we're doing the right things and making progress, meeting our goals.
I can call anyone at the corporate level, from the president to the CEO, any time.
HL: What has been the most rewarding part of your experience, so far?
Wan: Hiring my first caregiver and getting our first client. Our first caregiver is a retired teacher and our first client is a retired artist who came to us because she needed someone to help her while gardening for a few hours at a time. The caregiver lives 10 minutes away from her, so it was a great match.
We had them meet and they were able to develop a connection like normal friends, and that just blew me away. The three of us took a picture together, and it was just the most rewarding thing. The best reward.
HL: What's your advice for someone considering becoming a home care franchise partner?
Wan: First, as a business owner, if you want to open a business in this space, make sure you find the right franchise system that has the right model.
Find something that resonates at your heart level. Not because your demographic translators show there's money to be made. The financial part will take care of itself. The important thing is that you care about the lives you touch.
