On July 1, 2024, the CMS Innovation Center launched the Guiding an Improved Dementia Experience (GUIDE) Model, with 390 participating organizations building dementia care programs that will serve hundreds of thousands of people with Medicare nationwide. One of the GUIDE participants is a Seattle-based startup called Rippl, which recently raised $23 million in Series A capital to fund its multi-state expansion. Rippl Co-founder and CEO Kris Engskov recently spoke with Healthcare Innovation about the opportunity for value-based models in dementia care.
CMS has said the GUIDE Model, which will run for eight years, will be one of the first Innovation Center care models to focus on longitudinal, condition-specific comprehensive care. Today, nearly 7 million Americans live with Alzheimer’s disease or another form of dementia, and, by 2060 the number of Americans living with dementia is expected to double to 14 million.
After working for many years as a Starbucks executive, Engskov spent a few years running an assisted living company before launching Rippl.
HCI: Could you talk about what led you to co-found the company and the opportunity you saw there?
Engskov: Both my parents had very near misses with the long-term care system. They live in rural Arkansas. I admit that I was the most naive person in healthcare at that moment. However, I decided that I was going to bring some light into that industry. I invested in and went to run a fairly large assisted-living company based in Seattle called Aegis Living.
This was a year before COVID. We got into COVID pretty quickly caring for a highly acute population, mostly folks who were cognitively impaired. That was a war, trying to take care of the most frail people in America. I got a front-row seat to it, and I'm grateful for that experience. But I knew fairly quickly that I wasn't going to be able to make an impact in getting better outcomes in senior living.
Rippl was catalyzed out of an observation I made while I was there, which was that I was shocked by the number of times we would send our residents to the ER, because we could not manage their symptoms, almost always related to dementia. The families would call me and say we just handed our mother to you two weeks ago. Why is she in the ED? They would say, ‘I thought this is what you guys did,’ and I agreed with them. So I started to look around, and saw this was a big business problem. A significant percentage of the time when someone left one of our our communities and went to the hospital and got admitted, which happened often, they didn't come back to us.
I began to look around to try to find an intervention with a licensed clinician that we could access that would help us keep folks in place. What I realized was, and this sounds super dramatic, but it's 100% true, is that there's nobody in America who knows anything about dementia at any scale. We've never paid for that care, so we've never built the infrastructure. The medical piece has always been sort of compensated at some level, but the fundamental thing that actually keeps people at home, which is the caregiver, has never been supported.
HCI: So how can you help patients and caregivers?
Engskov: We found great work done both at UCSF and UCLA. The UCSF model was all virtual and had very good clinical outcome results, particularly around how to impact a caregiver to then impact a patient to stay at home. Ultimately, they were able to translate that into lower utilization, which obviously is the name of the game when trying to get this care paid for with an insurer. They were able to significantly reduce costs for these patients.
HCI: So what is the business model that you developed inspired by that work at UCSF and UCLA?
Engskov: We started serving patients in January of 2023 with a value-based orientation. We were going to go to payers and payviders and other risk holders and say, ‘Hey, look, this is a really expensive disease.’ We believe this is more expensive than lots of the other chronic diseases people often talk about, and it's just not well known for a variety of reasons. We decided that we could do a care model and take risk with payers to really have skin in the game, and reduce cost by having this service available. The big UCSF breakthrough was recognizing it's not just a patient; you have to have the caregiver involved. That's really the only way value-based can work, right? The caregiver is as much the patient as the patient, especially as they get to a place where they have reduced capacity, right? So it really good setup for value-based care.
HCI: What are some of the the services Rippl offers? Are they all telehealth-based, or is it actually going into the home?
Engskov: It’s entirely telehealth today. Everything’s delivered virtually. CMS’ GUIDE model came out this year. We started in that program in four states in July. That's a pretty big breakthrough from CMS, right? We now have a Medicare alternative payment model for delivering dementia navigation, coordination, and education.
We found ourselves in a really fortunate position, in the sense that we had started the company and built the care model. And it was the same care model that GUIDE ultimately used to inform their work for the most part.
HCI: Did I see that you partnered with the Alzheimer's Association on that?
Engskov: We have a national partnership with the Alzheimer's Association to build a GUIDE infrastructure. They’ve been a great partner. We’re very different animals, right? You’ve got a very large nonprofit that's in every part of dementia, and then you’ve got a tiny startup. What's funny about that is that when GUIDE came out, we started having this conversation with them about what we could do with this opportunity, because they have a great desire to deliver more care. They are the OG of who you call when you get dementia, and they have very big call centers to deliver a lot of advice, counseling and content. What we're providing for them is really a clinical arm where they can refer folks in our direction who are appropriate for our care, and we can get them into a longitudinal care that's paid for by Medicare.
HCI: When you first started with patients in January 2023, was that in partnership with a payer in Washington state?
Engskov: It was not. We were not getting paid very well in the beginning through fee for service. We quickly got into a value-based contract with a major payvider that I can't name publicly. But we are working for a large payvider in the Northwest today in a value-based construct. We've got the GUIDE program going now as well. So those are broadly the two payer models we have, and we have other value-based contract relationships that we're building now.
HCI: Let’s go back to the telehealth services. What kind of providers are typically on the other side of the screen? Is it a nurse or a physician?
Engskov: Our care model is an advanced practice nurse practitioner, a licensed clinical social worker, and then what we call a care navigator. They're all experts in dementia. Those three folks work together in a virtual pod. They follow a patient longitudinally, and when I say they follow them, they individually follow that patient. Because one of the key things here is that it's not like traditional care management. You have to know the patient to be successful in this particular chronic disease. You have to know their history.
In many instances, a care navigator who is unlicensed, but is an expert in dementia knows that patient and is kind of the quarterback for the family. That caregiver is as effective at avoiding ED visits as more advanced clinicians, because so much of the problem we're trying to solve is behavioral.
One thing that was a surprise to me when I first started the company was that I thought this was going to be like a crisis line. You call us when it's 8:30 on a Tuesday night, and you don't have anyone else to call. You can't reach your PCP, and we help you manage the situation. However, we get very few crisis calls because we're so far upstream. One of the great surprises out of this is that we are identifying issues earlier before you need to go to the ED.
HCI: What are a few of the things that this new funding can help the company do?
Engskov: We will use the money for two or three significant things. One is, we will broaden our geography. We are in four states today. We will go to other places that we think would be good candidates for this kind of care, and are set up for it. The second part is a bigger team to help us go find the partnerships that are necessary to set those up. GUIDE is great. We can go to a state like Florida and begin to serve patients because of GUIDE. But we also want to find other partners that we can work with in value-based arrangements.
We might be one of the very few companies in America with a value-based contract around dementia. I think it's primed for innovation, especially given the volumes of people that are coming. So partnerships will be a big part of it. And we have several that we're really starting to build out.
We've also got to build this on a pretty robust tech platform. I think there are some really practical ways that AI can help us expand this care with more precision. The first way we're going to use AI is really as a digital assistant sitting behind our care navigators, listening to unstructured conversations and, helping them capture detail, prompt asking the right questions at the right time, suggest resources that a caregiver might need.
HCI: Where did the company's name come from?
Engskov: It is from a Bobby Kennedy speech in 1967 in South Africa. He had this great phrase called the ripple of hope. His point was basically that when you're trying to solve big societal issues, you’ve got to start with a ripple, and those things tend to build. We took the inspiration from that, because the problem here is that we don't have anybody that is trained in dementia care at scale. We see ourselves as much about building a workforce as we do providing this care, because we can help get a lot of people proficient. So we like the idea of creating a little ripple here around workforce.
HCI: And then you left the ‘e’ off the word ripple.
Engskov: Well, try to buy a URL. The only thing harder than starting a healthcare company is actually getting a place on the web where you can exist before you start.
