The Quest for the Future of Care

What does it truly mean to live a “normal life”? In this episode of The Quest for the GoodLife, Dr. Mike Strouse and Ivo Ivanov explore how technology, shifting expectations, and the lessons of the pandemic are transforming care. From “place killers” like Netflix and Amazon to the enduring vision of the Final Rule, they reimagine what’s possible for people with disabilities, seniors, and communities everywhere.

Join us as we uncover how care must evolve beyond old models—like Blockbuster and group homes—toward a future where people have home-field advantage, time for what matters most, and support that fits seamlessly into everyday life.

Transcript

Dr. Mike Strouse (00:13):

Hello everybody. I always talk about the never ending journey, and today we're going to talk about that journey to the next generation of care. But anytime you start a journey, a real one, you need to know where you are and how you got there and where you're going. And I think that that's what this episode is a about, is trying to look at this journey that we need to go to. And that journey really is to the vision of the final rule. And everybody in our industry knows what the final rule is, Ivo, but I think it's important to make it simple. And the final rule at its core is living a normal life. What everybody wants for people with intellectual disabilities, for seniors, for everybody, is they want, if they have a need for support and care, they want those needs met, but they want them to lead a normal life. That's what they want. And that's pretty simple vision. We all know the tragedies of the pandemic, but at the same time, and I think it's true with a lot of tragedies, there's a silver lining with every tragedy, I think,

(01:39):

And the pandemic has changed us forever. When I do virtual presentations, I mean all the time. I would tell you three quarters of all the people that I meet with are working at home. We're talking about industry leaders and managed care, industry leaders and community services. The people I meet with more than not are not in their office. They're working from home. And they chose to do that. It wasn't that they have to, they chose to. And when they had to do it, and then they came back to where they don't have to do it, it's clear that they want to. So what resonated with people, do you think? What is it?

Ivo Ivanov (02:30):

I've read somewhere recently, the average life expectancy of an American is about 42 million minutes, and it seems like a lot, 42 million minutes, but before you know it, it's 20 million minutes. I'm looking at my life now and I'm looking at 10 million minutes and I don't want to spend 45 of those precious minutes stuck in traffic going to the store, going to work. I want to spend those minutes in the most functional possible way. I want to be able to have extra time to be with my loved ones, to be with my children. I want to extract as much value as possible from my life, from my 42 million minutes. I think people instinctively, they might have not read this, they might not think about life in minutes, in terms of minutes, but they instinctively know how valuable life is and how valuable time is. It's really the only currency that will never lose its value. It only gathers more value. So I think that people understand

Dr. Mike Strouse (03:49):

That. And the other part about it is life is organic. And I use this word is life ebbs and flows. And I was talking to my friend Mindy the other day, and she had to be at home because they were delivering furniture. So she was working from home and it's like, well, they only delivered furniture 10 minutes, but she didn't know when those 10 minutes were going to be.

(04:11):

So it was just great for her to be able to do that and to be available to do that. Last night I went to the Chief's game and we won. We won. It was a very hard game, but I had a meeting right before that and I chose to take it in the parking lot, my car on my Google meet on my phone, and I could do that, but I was able to live my life and intersect a really critical meaning that I had to have that I couldn't choose when it was going to be, but I could do it organically as my life unfolded in a way that didn't let me miss out on something that I really wanted to be part of. And by the way, I went there with my son and it was super important to do, but that's why people love it. They want to live their version of a life and they don't want places to get in the way. I use the word place, it's like going to a clinic. That's a place, right? And I'm not just talking health. I'm saying the store's a place.

Ivo Ivanov (05:23):

Yes,

Dr. Mike Strouse (05:23):

Blockbuster

(05:25):

Was a place. What happened is the right word. What in the heck happened to Blockbuster technology? Technology took it away. It was a place killer, wasn't it? It was a place killer. And that's what I see is technology has been place killers. It's allowed us to redefine what's possible for living a normal life. I mean, I love an old philosophical mentor, was a guy named Wolf. He was the guy that created the concept of normalcy, of living a normal life that people with intellectual disabilities wanted a normal life. They called it normalization. They wanted a normal life. Well then normal life, that was the seventies. And by the way, we haven't got much closer to what his vision was. And now the final rule has taken his vision and recasted it and recasted it and recasted it. The vision doesn't really change. The only thing that changes is two things. What's the normal life changes right now that and our capabilities to do it change. But I don't know, sometimes we're the last people to, as an industry, to adopt what everybody else has adopted already to make things happen. And we've been killing places for a long time, and I think the pandemic took that to another level.

(07:09):

But I say killing places more specifically. We know that Blockbuster had a business plan where they had a store and we all went to the store, and you got to look at why did they have the store or a grocery store is a place we go. A clinic is a place we go. These are all places. So why do they exist? I mean, if you want to sort of change something, and I'm a behavioral analyst, so I always think this way, but if you want to change something, you got to understand why it exists because there's a function to it, right?

Ivo Ivanov (07:49):

Yeah. Provide a service.

Dr. Mike Strouse (07:50):

Well, and they do it. The reason places exist to provide goods and services is because it was delivered on their terms and a way that they could control it was on their terms. But this is the coolest thing, and I think it talks about normalcy is what did we just figure out? Well, everybody doesn't want to go to places that delivers things on their terms anymore. They,

Ivo Ivanov (08:17):

There's a lot of things that come up with, there was Blockbuster, we mentioned Blockbuster. Then you had to go and go through their selection, search for the right product for the right movie, take it back. Then you go back, and then you have to deal with late fees occasionally because you don't always have the time to return the movie on time

Dr. Mike Strouse (08:38):

Where you lose it.

Ivo Ivanov (08:39):

Yeah,

Dr. Mike Strouse (08:41):

My kids lost it.

Ivo Ivanov (08:42):

Yeah, I've lost it sometimes. But really the biggest fee we pay is those precious minutes that take away our time, our life. And I know change is hard, but progress is inevitable. And technology provided us with all of these products, all of these movies, on demand when we want it, we can see the trailer, we can decide right from our calm whether we want this product or not.

Dr. Mike Strouse (09:13):

Exactly. Everything has been hit by technology in a way that has ended the store. It's a place killer. It's a place killer, basically. It says it. Nope, I don't want to live life on the clinic's terms. I don't want to live life at hyves terms or a storage terms. I don't want to go to Blockbuster. I want things on my terms, and I want home field advantage. I like that. We want home field advantage. We want to be able to start a meeting in the meeting, have a cup of coffee, walk the dog, have another meeting, go in our own little study and work for a little bit and then go to lunch with our wife. I mean, it's a great life. Now, not everybody can live it. Maybe you can only live it partially, but we're only living it because of technology. I mean, when Amazon started, well, when Netflix started, for example, it was they mailed you stuff.

Ivo Ivanov (10:23):

Remember

Dr. Mike Strouse (10:23):

They mailed it, they didn't do it, but I think their vision was exactly what's happening. But I think they just looked at, well, okay, what's possible? And mail did it first and you had to do the return thing. And then pretty soon, BroadB band speeds and other things changed to make something possible. Then you got the downloads, and from there you got live TV where it's not even downloading anymore. Now you have streaming tv. I mean the evolution. But the evolution happened at Netflix because it was the vision from day one. I think you know what the vision is, it's Bewitched. Remember Bewitched where all of a sudden Samantha twinkles her nose and then she got what she wants, and then it went away. She would get something and it would go away. I mean, you lived your life and then you could actually, if you could just snap your fingers and get what you want, and then it goes away, and then you get on with your life, and then you need something or want to do something else, you snap your fingers. And then wouldn't that be, I mean, that could be the vision, right?

Ivo Ivanov (11:34):

GrubHub and grocery delivery and you snap your fingers or your phone app. And

Dr. Mike Strouse (11:44):

So we're kind of caught in that world in care

(11:49):

Where we're going to probably end up walking in both because people need human help and they want the human connection. But there's a lot that technology can do. And just like Netflix, it gets better, but it gets better only if you have the vision and only if you are working very hard to move towards it. But I think going to my presentations I've done with people, I've always, I've talked to them and we're having the worst crisis of staff. Well, yeah, we are having our staffing crisis. But one point, I've been around for a long time, as you know, and we've been having a crisis of direct support capacity since community services started. And I mean, Dr. David Braddock was a huge author in 1995, and he published a study about the turbulence of our workforce and claimed that even at that time, it was the most unstable workforce of all industries.

(13:02):

And sort of what's changed? Well, it's still, it's actually much more unstable. Mean right now, today, as we set community services averages 32% part-time, I think post pandemic and where we are now, I think we're closer to a hundred percent turnover than 50, which was what we were before the pandemic. But when you look at a number of different people involved in care, that's because of vacancy rates where you have to use replacement staff or high turnover or people taking vacations and every other thing that causes different people involved in care. You may have four times the turnover rate of the number of different people involved in care across time. That's what our research is showing. So I've started asking every one of my conferences, presentations the same question. I said, okay, you guys all know the vision of the final rule. If we were having people served in one or two person placements today, how many of you have or believe it's even possible to have the labor and stability to deliver that? I mean, every time hundreds of people, I've never had anybody raise their hand. When you put that on the back of 50 years of instability and the trends for senior care and all of that is ahead of us. So thousands of people on the waiting list, how could we even pretend that we have the workforce to deliver the vision of the final rule?

Ivo Ivanov (14:48):

Anyone at those conferences giving you feedback about their vacancies? Is anyone being happy with what they have right

Dr. Mike Strouse (14:59):

Now? Well, we work with 30 agencies on improving it. The number one problem really is people just gravitate to pay, but it's really not pay. It pays important. But the biggest issue is wonky schedules. You're trying to schedule your time in that home, but you can't do that because you don't know when the need is.

(15:24):

So people always end up overcorrecting and they have to be there because people's needs are critical. And so all of a sudden they're trying to piece together how they're going to support somebody and be there. But that doesn't line up to any schedule at all that somebody could have. So I think we're really getting to the point of this whole thing, and that is there's a vision of the final rule, and that vision isn't a stinking bit different than Wolf Berger's vision that was in the seventies. It's no different. It's that people want to live a normal life like all of us and get the help they need when they need it. We need to be focusing on the Netflix. Exactly. And we can't just, exactly. Because Netflix isn't just blockbuster with technology.

(16:31):

Netflix is what was technology made possible, and it's in completely an utterly different business plan. And that was true with Amazon. It was true with Instacart, and it's true with GrubHub, and it's true with Station md. Technology made a different approach possible. They don't bolt that technology onto some traditional approach. They did not do it. They started with what was possible and they reconceived how do you deliver services or a product or whatever with this new possibility. And that's where we are right now. And I dealt with families who didn't want to leave the institution, and they said some of the same things that I'm hearing now that some people might say about a group home,

(17:19):

And that is, I like the fact that the supervisor is in the home. I'll call it the store. Let's call it the store for a second. I like the fact that there's two eyes, two sets of eyes on care. I want to make sure that the care is of quality, whether it is or isn't. I want to make sure that my loved one is safe and not being mistreated because he can't advocate for himself. I want to make sure that somebody new, the new staff, and there's always the new staff has somebody that's been there a while to help 'em learn what to do when the need arises, right?

Ivo Ivanov (18:04):

Yes.

Dr. Mike Strouse (18:05):

So I want at night there to be somebody available right then to help somebody, even though there may never be a need for help, right?

Ivo Ivanov (18:15):

Yeah.

Dr. Mike Strouse (18:16):

So there are specific reasons an institution existed and we needed to come up with a way to do it different, to take those reasons away. And we kind of invented group homes at the time. Now we have group homes and there's a lot more reasons than that. I mean, excuse me, cost to housing, things like that are in there too. Two, a big van for transportation. There's other reasons. And I think it's important we identify those reasons because that's where the, remember we talked at the beginning, if we want to journey somewhere, we need to know where we are and why we're there. So kind of bringing this thing home is the journey starts from the group home a place. It's a place that we send people for care. It's not through home. And I don't want to mean that it's not homey. It could be homey, but it's not their home. It's a place we send people for care. It's Blockbuster. It's a store.

(19:32):

And so why did we do it? Well, we did it because the reason that I said, we want multiple staff there so they can learn from each other. We want a supervisor present. Most of the time. We want somebody up at night. We want a big van because it's cost effective. But basically all of those are reasons why the store exists. And it's delivering services on the terms of the owner of the store. And that's the provider. And I'm not talking about things I haven't been part of. I'm not trying to in any way do that. But that's where the journey's starting. It's starting from the store, and there's darn good reasons why it exists. We need to identify every one of those reasons, just like Netflix did or Amazon did, or Instacart or any of the other places, the remote clinics. And we have to say, okay, how can we take those reasons away?

(20:31):

And how can we keep our two sets of four sets or 15 sets of eyes on the prize, which is how do we deliver a normal life? And then realize the normal life is different now three years later. It's different than it was three years ago. And now the goalpost way has moved on. What a normal life. And it's a much better life. That's why we're sitting here having a discussion like this. A normal life is our real life, and we're getting the stores and the jobs and the travel and everything out of the way, and we've kind of got a version of Bewitch going on here. And it could be pretty cool. But that's the vision. That's where we are. And the journey is how do you get there? And that's what we're going to have to start talking about. The technical term of it is technology, leverage services, but really what it is, it's a new business plan and uses technologies in ways that deliver something better.