Dal Ben Home Care & Senior Care – Best Use of HR WINNER – 2018

Sao Paulo based post acute care and home care business employs 350 members of staff and makes an average of 5,000 home care visits per month.

In Brazil, home care has traditionally been provided by workers in the informal sector, reducing costs but resulting in a negative impact on quality. Dal Ben has shifted and formally employs all its staff increasing staff retention and allowing it to focus on training centred around culture, brand, and service quality. Since making the shift, the company saw a 50% reduction in staff turnover from 2015-2016. It also led to a reduction in average complaints per visit from 0.31% to 0.19%.

Dal Ben is a leading home care company based out of the city of São Paulo, Brazil. Founded in 1992 by Dr. Luíza Dal Ben, the Company is a pioneer in the Brazilian home care industry, with strong focus on high complexity cases, a consolidated out-of-pocket client base, and close relationships with leading Brazilian HMOs and hospitals. In 2014, a professional investor team with a wide experience in healthcare, logistics and finance acquired the controlling interest in Dal Ben, improving governance, professionalizing management, and adopting high standards of controls and operating performance. As part of the implementation of its long-term strategy to become an integrated post-acute care provider, the Company raised capital from a family office in Brazil on March 2017. Furthermore, on May 2017, Dal Ben acquired Althea – Clínica de Apoio ao Paciente Crônico, a 25-bed post-acute care facility located in the city of São Paulo. The post-acute care market in Brazil is highly fragmented, and Althea is perceived to be one of the leading post-acute care hospitals in terms of quality of service and infrastructure. The acquisition was Dal Ben’s entry in the post-acute market in Brazil, establishing Dal Ben as a pioneer in the integration of homecare and post-acute care services in the country. Currently, the Company has over 350 employees making an average of +5.000 home visits per month. Dal Ben is expected to reach approximately R$ 50 million in revenues in 2018 and has grown +47% and +35% in 2016 and 2017, respectively.

Dal Ben provides a wide range of medical and non-medical home care services to private and institutional clients, which includes: (i) Medical Home Care (Mechanical Ventilation, 24/12/6hs), (ii) Specific procedures, (iii) Palliative Care, (iv) Inventory management of materials and medicine, (v) Chronic Diseases Management Program, (vi) Management of Hospitalized Patients, (vi) Multidisciplinary team of visiting doctors. In addition to these services, for out-of-pocket clients the Company also offers: (i) Elderly care programs – senior home care (24/12/6hs), (ii) Family advisory for elderly care, and (iii) Nursing support at hospitals and clinics.

At Dal Ben’s post-acute care facility, the Company provides 24-hour hospital services for rehabilitation patients and long-term acute care. The integration of home care and post-acute care allows Dal Ben to coordinate care continuum between the two segments. Patients at the clinic can be discharged with follow-up homecare services to continue low acuity medication or therapy. Also, patients at home that need higher acuity care can be stabilized at the clinic, avoiding higher cost hospitalizations at general hospitals and resulting lack of coordination among medical teams and staff.

There are likely to have been several changes to practice. This could include a transfer of processes from, say, doctors to nurses, which cuts costs and saves time. It could be a cultural change programme, which dramatically improved patient or resident care or treatment. Or it could be a training programme that led to big skill improvements. Please list the changes separately.

Change 1 : In Brazil, medical and non-medical home care services have been traditionally provided by nursing technicians and assistants who are not formally hired by service providers. Although this reduces significantly labor costs, as informally hired labor does not require the payment of several taxes and social security contributions, this hiring method has significant negative implications in the quality of services provided. In addition, it generates material labor liabilities to companies, families and HMOs. Dal Ben has been one of the first companies in the country to successfully use formally hired labor in homecare, which, in turn, brought several important benefits to our operations: (i) allowed the Company to invest in training programs and capacitation of internal staff, (ii) decreased volatility of crews allocated to a client, (iii) mitigated labor liabilities, and (iv) improved assistance at home with a more committed and better trained staff. As a result of formally hiring its employees, Dal Ben was able to invest in the development of a comprehensive training program for nurse technicians and assistants. Currently, there are two training programs implemented by the Company, the Integration Program and the Continuing Education Program. The Integration Program aims to introduce new employees (nursing technicians and assistants) to Dal Ben’s universe, facilitating the beginning of their careers in the Company and their effectiveness is assisting patients. This program has the duration of 75 hours and is divided in four main modules: o Human Resources: provides an introduction to the Company, rights and duties of employees, and their legal rights relating Brazilian legislation; o Culture and Behavior: addresses the different aspects of care, taking into account the values and culture of the company. During this module, employees are trained to behave in the client’s home environment, addressing their specific needs and demands; o Ethics and Legislation: focused on discussing the laws and regulations that support the professional practice of nursing assistants and technicians, as well as the legislation applied to Home Care; o Technical Development: during this module, several important technical procedures are reviewed, aiming to improve and standardize technical knowledge among all nursing technicians and assistants. The module focuses on theoretical and practical knowledge where several real life situations are simulated and results/solutions are discussed in the classroom. The Continuing Education Program is intended for Dal Ben technical staff, focusing on the technical and behavioral improvement of professionals according to their specific needs. In many circumstances, they are invited to participate in specific modules of the program intended for integrating new employees.

Change 2 : The integration of homecare and post-acute care services in Brazil brought additional challenges to the HR model initially established in Dal Ben’s homecare business. Integrating assistance protocols, HR processes, and culture was a significant challenge during the post-acquisition integration. The first step was to build an unified and concise medical team, under the supervision of a Clinical/Medical Procedures Committee to oversee and review all processes and protocols, emphasizing the utilization of synergies and best practices. Second, was to unify HR protocols, eliminating potential labor liabilities at the new facility and ensuring the exchange of knowledge and experience. Third, was conveying to the team the strategy and operating advantages of having both businesses integrated, assuring the people at the point-of-care have the same message and understanding as management and shareholders as of why we are working the integration process.

Our training program started in May 2015, and its impact was felt in the operations almost immediately. The training programs promoted greater cultural and institutional alignment, as well as improving the quality of the services provided. There was a reduction in complaints regarding the technique of professionals and greater adherence to operational protocols.

The integration efforts started immediately after the acquisition of the post-acute care facility. After a few months, we already can identify significantly higher levels of coordination, optimization and care integration among the team.

Regarding the Training Programs, the key performance indicator measured by our company are trained staff ratio, hours of education, turnover, customer complaints, absenteeism and technical deviations.

Prior to entering the training program, each employee is evaluated through a test of their technical and common knowledge. After each module, they are submitted to take a test of the content taught during that particular module, whose results are compared to the initial test. The goal is to conduct an ongoing selection process, allowing the Company to dismiss employees not capable of absorbing the knowledge throughout the course. This was an important element in reducing labor costs, as we were able to dismiss low potential employees during their experience period (according to Brazilian law, firing an employee during this period reduces several penalties and social contributions).

After the completion of the training program, we measured several other indicators associated with our overall quality and customer experience. We observed a significant drop in turnover and absenteeism, specially changes within the staff allocated to a single household. Average turnover in 2016 dropped by 50% compared to 2015, when we started the program. Customer complains decrease materially, specifically the ones associated with staff or technical problems. For instance, average complains measured in 2015 were 0.31% of all visits in 2015, compared to 0.19% in 2016. The same training program is being delivered at the clinic, we consolidated training, HR controls, and back-office functions, which, in turn, has led to increase in efficient and improvement of the Clinic’s financial performance.