As the need for behavioral health services continues to grow, so do the number of companies trying to creatively meet the demand.

For some, that means introducing new technology and remote monitoring solutions in an effort to improve outcomes. For others, it means repurposing existing models of care in new ways — which is the case for Massachusetts-based home health care provider Nizhoni Health.

While most home health care companies build their operations around taking care of older adults with chronic medical conditions or those who have recently returned home from the hospital, Nizhoni has leaned into mental health treatment specifically.

The five-year-old company almost exclusively serves complex behavioral health patients with multiple health needs, providing services that include skilled nursing, home health and therapy. While a typical home health patient might be 70 years old and homebound with congestive heart failure, Nizhoni’s go-to patients are often younger, mobile adults suffering from schizophrenia and other acute mental illnesses.

“We provide care to a very distinct population,” CEO and founder Joseph McDonough told Behavioral Health Business’s sister publication Home Health Care News.

Currently, Nizhoni and its team of roughly 700 nurses care for patients located across Massachusetts. On average, the provider carries out about 20,000 patient visits per week, though that number is rapidly trending upward.

“We’re probably one of the fastest growing agencies in Massachusetts,” McDonough said. “There’s such a need, so we’re certainly busy trying to fulfill that.”

When it comes to reimbursement, Nizhoni receives some money from Medicare, the payer typically associated with home health care services. However, most of its funding comes from MassHealth, the state program that combines Medicaid and the Children’s Health Insurance eProgram (CHIP). There are more than a dozen Accountable care organizations (ACOs) operating under MassHealth, and Nizhoni partners with them on a regular basis, too.

Navigating the Massachusetts Medicaid landscape is one of the biggest difficulties that Nizhoni faces, McDonough said, noting that workforce shortages are also a challenge.

At an estimated $16.7 billion, MassHealth accounted for about 36% of total estimated state spending in fiscal year 2019, according to the Massachusetts Budget and Policy Center. Yet funds frequently fluctuate from one year to the next.

“Working with Medicaid is always challenging,” McDonough said. “There have been cuts in the system in the last few years. For us and our patients, I personally believe more resources should be put into this population — at least something commensurate with the costs that they [present].”

Health care’s highest utilizers

As somebody who has worked in the psychiatric space since the 90s, McDonough knows all too well how costly Nizhoni’s patient population can be to the health care system if left uncared for.

Prior to launching Nizhoni, McDonough served as a mental health worker and home health nurse in Connecticut. After that time spent on the ground, he earned a graduate degree in psychiatric nursing from Yale, got engaged to his wife and then decided to permanently move back to Massachusetts, where McDonough is from.

It was at that time he noticed a clear gap in the market.

“I looked at the landscape here and realized that, even though there are a lot of wonderful [home health providers], they were more geared toward the geriatric population,” McDonough said. “At that time, there really weren’t services that were geared toward the complex behavioral health population, so I decided to start this company.”

In general, Nizhoni’s patients are the health care system’s “highest utilizers,” or the 5% of complex patients that account for roughly 50% of all costs. On top of their acute mental illnesses and multiple chronic conditions, many Nizhoni patients live in low-income areas.

“This is a very, very high-utilizer group that needs a real intensity of service — many times 365 days a year. There’s no days off,” McDonough said. “Our nurses probably performed about 2,000 patient visits on Christmas last year. And in a majority of cases, our nurses were probably the only people that that our patients saw that day.”

In Massachusetts, the average hospitalization costs about $28,000 and lasts 11.3 days, he said. Without in-home care, the type of high-utilizer patient that Nizhoni serves would be in and out of the hospital 10 to 20 times per year, McDonough added.

In comparison, the average annual cost of Nizhoni’s services is about $23,000.

“[Policymakers] are paying attention to this population,” McDonough said. “They’re realizing that there really is a great value proposition for home health to move these patients into the lowest-cost care environment. And, frankly, integrate the system so that there is a unified continuum of care for these folks.”

Expansion expectations

In terms of current profitability, Nizhoni Health isn’t exactly breaking the bank, McDonough said, as Medicaid reimbursement is typically low, in addition to other challenges. The company declined to provide details on its revenue or operating margins.

McDonough sees the tide shifting, however. As more states and payer sources begin to realize the value of keeping complex behavioral health patients at home and out of the hospital, he argues, more business opportunities will start to open up for companies like Nizhoni.

To help fuel that realization, Nizhoni is actively investing in data capabilities that help demonstrate its positive health outcomes and savings.

“I firmly believe that within the next five years, if you don’t have the data, you’re not going to be able to compete in this industry,” McDonough said.

Once armed with the necessary data, Nizhoni will look to grow — and fast.

Overall, 4.6% of U.S. adults — or about 11.4 million people — experienced serious mental illness in 2018, according to the National Alliance on Mental Illness. Only 64% of that population received treatment for their conditions.

“We’re looking to create a platform that can scale nationally,” McDonough said. “Because the same problems that exist in Massachusetts also exist in Texas and also exist in Colorado. They exist in Ohio.”