Jukebox Health has developed a predictive model to identify individuals at risk of functional decline before a medical crisis occurs. The company’s executives recently spoke with Healthcare Innovation about how they partner with managed care organizations to address how functional independence drives healthcare utilization and home and community-based services costs among Medicare-Medicaid dual-eligible populations.

We spoke with co-founder Oren Shatken as well as Chief Medical Officer Richard Feifer, M.D., M.P.H.

Healthcare Innovation: Oren, How did you identify this need in terms of connecting home modification and safety services to clinical outcomes and independence?

Shakten: My mom was an occupational therapist. Growing up, I always had a deep appreciation for how our environments impact us, both physically and mentally. My father is an architect, so it kind of came from both of them. In college I got into technology and software development and startups. Eventually, I built three companies before this one. The first two were in home services. My first company was bought by Angie's List. I slowly found myself gravitating toward companies in healthcare where I felt that investment of time and effort was going to be more impactful for the world. My third company, which was acquired by Elevance, was a healthcare services business,. My co-founder Romanos [Fessas] approached me about doing something together, and it felt like the intersection of healthcare and the home was an unexplored and interesting area, one that I felt uniquely qualified to work on, so about five years ago we decided to embark on this journey.

HCI: Dr. Feifer, how were you drawn to the company?

Feifer: Well, I've been working since the 1990s, since I was a trainee in internal medicine, on population health and value-based care models. That’s always been of critical interest to me because ultimately the way to reform and improve and optimize our healthcare system in the U.S. is by shifting greater accountability to providers for caring for populations, especially those with serious illness and those with declining status. I’ve been working on that for years on the traditional Medicare and commercial side, on the Medicaid side, but also with regard to functional independence. 

In fact, my most recent position was in the PACE [Program of All-Inclusive Care for the Elderly] world. The PACE world takes a holistic view of all of its program participants, thinking not only about medical care, medical costs and medical outcomes, but also functional independence, functional ability, allowing people to have the greatest level of function and the greatest independence, and in doing so, by the way, also managing the skyrocketing costs of support for those who have functional decline. 

What I was very excited about when I first met Oren and Rom at Jukebox was that their approach was very different than many other organizations. Many others come at this question with a traditional medical model, looking at medical illnesses, medical predictors, medical costs, and medical outcomes. Functional statuses may be off to the side as a corollary. Their focus was exactly the opposite, saying functional status is the lead. Let's go after that. Let's identify what the predictors are of declining functional status because if we can address that, we will actually mitigate and reduce adverse medical outcomes and costs on the medical side. It put the primary focus on function and functional independence. It's a very interesting and a unique perspective. That's why I'm excited to work with them.

HCI: Was there already a body of evidence that functional status decline is an early indicator of future medical problems?

Feifer: There is an emerging body of published evidence over the last five to 10 years, so this is something that is evidence-based.

HCI: How did the company get off the ground? Did you find a Medicare Advantage plan that wanted to partner initially on this?

Shakten: My bias is as an entrepreneur, and I really want to learn by doing. In my prior business, we had partnered with Medicare Advantage plans, and I knew that contracting with health plans takes an extended period of time. I didn't really want to wait on that. So the founders just put a little bit of money together and we said, why don't we learn by doing 10 of these projects? We'll put up a sign at the local senior center. I'm sure we can find somebody who would benefit from this, and we'll learn a lot from how the member or the patient experiences this project, and we’ll learn from operationally doing this stuff. That was eye-opening. We saw how much impact we could have in a concrete way and that gave us the fuel to push forward.

HCI: Does this involve things like installing grab bars in showers and ramps?

Shakten: We're finding there is a long tail of solutions that are deeply specialized and personalized for people. Everybody's seen grab bars or stair chairs and things like that, but every day there are new products coming to market in the adaptive technology field that can help people with all sorts of specialized conditions and functional gaps to live safely and independently in their home.

HCI: So did you eventually develop partnerships with managed care plans? 

Shakten: We did partner with MA plans but it took us a little bit longer to find Medicaid LTSS waiver-eligible individuals, and particularly those who are cared for under fully integrated dual models, where we could have the most impact because the payment model was truly aligned to provide the types of services that we thought were most impactful for that population.

HCI: So is the dual-eligible population a key focus? 

Shakten: Yes. When we talk about the impact that we want to have, it's about safety, health, and independence. Independence is really impactful on the Medicaid side because it means that you're staying out of nursing homes and you're less reliant on personal care services. But keeping people from falling, keeping them healthy from infections, and out of the emergency room — that obviously has a huge impact on the medical side, so there's value to tackling those problems independently. But when you put them together, there's so much compounding effect that I think it makes it a no-brainer.

HCI: How did you put together a big network of occupational therapists and installers?

Shakten: This is my third time building a national network of home service providers. I'd done it at another company that was in the home warranty space. There’s a set of tools and almost a playbook that felt quite natural for me. I think it's really important that you get high-quality providers that care about doing this type of work. One of the highest qualifiers is somebody who raises their hand and says, "I want to serve this type of population.” 

On the occupational therapy side, that was where I was less familiar, but was really positively surprised. Obviously, I had interacted with my mom. I knew what the scope of practice was, but I think what we uncovered as we started to work with more occupational therapists was that this is exactly the type of work that they dream about doing when they go to occupational therapy school — to work proactively in the community with people. Unfortunately, the mass of occupational therapy jobs are usually more in the inpatient context. We tend to find people who are really excited about doing this work. The individual who goes into the home understands that member's needs, has a 90-minute conversation with them about what their goals are around independence. That's what really makes this work at the end of the day.

HCI: Dr. Feifer, could you talk about your role in all this coming from the clinical side?

Feifer: I'm actually focused on helping us expand the model beyond where it is now, which is on functional independence through home modifications, directly impacting Medicaid costs, as Oren just described. We are thinking beyond that, more holistically across total cost of care and total outcomes, and having the occupational therapist practice at the top of their license, bringing in other clinical professionals as well, potentially nurse practitioners and others, to think about supplementing the health system for these very frail home-bound individuals. In many cases, we’re thinking about how to supplement the healthcare system to help them achieve those outcomes of avoiding hospitalizations. In some cases, these patients are within a few years of the end of their lives, so we want to have the goals-of-care conversations. Having goal-concordant care is something that the healthcare system struggles with and something that we can help with.

HCI:I just was interviewing somebody who was involved in the high-needs ACO REACH program, which is now transitioning to the LEAD program. Are those kinds of alternative payment models places where Jukebox could fit?

Feifer: Whether we fit within those payment models or adjacent to them, we're focused on the same issues for a somewhat similar population. Whether it's within a LEAD high-needs track or a PACE program, it's the same fundamental set of issues around medical and functional independence that we all are trying to tackle. We’re just coming at it with different payment models, but clinically it's the same underlying set of issues.

HCI: Is the assessment sometimes that the person really can’t be independent in their home and they should move into a setting with more care available? 

Feifer: You're asking a really important and good question. The way I'd start with the response is to say that every individual has agency. Patients can choose what degree of risk they want. They want to experience that goal-concordant care. Our role as the healthcare system is to help make that situation as low-risk as possible. There are certainly times where the clinical system says there's only so much we can do to make the home safe, and it might be safer to be in another environment with a greater level of assistance. But that's the patient's and the family's decision.

HCI: Have you had enough experience with these dual-eligible payers to say it's having an impact on hospitalizations or emergency department usage in a positive way?

Shakten: We're definitely starting to see some data that's pointing to that. There's a program that we did in New York that demonstrated that when social needs were met — things like keeping people's environments mold- or pest-free — that it reduced hospitalizations, so there is quite a causal link there. We've also seen strong validation of our ability to keep people independent. One of our proudest achievements is we were able to demonstrate a 4.5x ROI by helping preserve members’ functional independence through changes to their environment.

There weren’t any tools for predicting functional decline in a population, so we built a model that with a 95% true positive rate and 92% true negative rate can detect whether somebody's likely to decline in the next six to 12 months or stay at their same level of functional status, which is really critical to getting people the support that they need and helping keep them independent for as long as possible.

HCI: Have you expanded nationwide? 

Shakten: No. Now that we've zeroed in on the dually eligible population, our work is focused on a more local approach, so we're in about 10 states now, but we're constantly expanding.

HCI: Dr. Feifer, you mentioned expanding the model. Is that something that's already happening or is it on the drawing board?

Feifer: It’s something that we're developing right now, and we're working with different health plan partners to figure out how that can best marry with what they're already doing. What we're finding is that many of them have opportunities that they haven't focused on, so we're looking to find that spot where we can work in close conjunction with their care management staff.

HCI: Oren: is there anything else that you're looking forward to that I haven't asked about?

Shakten: I think the last thing that we didn't really touch on yet is that we've been making a lot of exciting investments on the technology front. In particular, at the beginning of this year we acquired a company called Braided Health, which has been building a care manager enablement tool. 

For this dually eligible waiver population, the role of the care manager, who usually either works for the health plan or for a local agency, is so impactful. They're helping coordinating transportation, meals, and doctors' visits.

Unfortunately, this being a smaller corner of healthcare, it hasn't received the same level of investment in technology innovation as other programs. We think there's a great opportunity, which is why we’re building specialized technology tools for these care managers. It helps them reduce the amount of time they are doing manual documentation, gives them cues about care gaps that they might miss during a course of a conversation or from disparate data sources that are being aggravated for them. It empowers them with the capabilities that they need to provide the highest quality care.