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This podcast is available on 4 platforms including Apple Podcasts, Spotify, and more. You can also use the RSS feed directly.

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Last Visit First

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by Tom Maxwell

5.0(2 reviews)

46 episodes

Updated Daily

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Podcast Overview

Most care stories in home healthcare end with the last visit. Last Visit First podcast starts there. Hosted by Tom Maxwell — a nationally respected healthcare veteran with over three decades of experience, Co-Founder and Chairman of Maxwell TEC, Maxwell Investment Partners, and Maxwell Advisory Group — this podcast features honest, unfiltered conversations with the founders, CEOs, clinicians, and innovators shaping the future of home health, hospice, palliative, and post-acute care. If you lead, operate, or believe in the power of care in the home, this is your podcast. Subscribe to listen.

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Publishing Since

9/3/2025

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Recent Episodes

July 19, 2026

Running a Hospice Company Around Family, Not Fraud: Phillip Fulgham

The biggest problem in hospice isn't fraud, it's patients waiting too long to choose it.Tom sits down with Phillip Fulgham, Vice President of Hospice at Saad Healthcare, a family owned home health and hospice company based in Mobile, Alabama serving the state's southern counties and coastal Mississippi. Phillip has led Saad's hospice service line since 2017, continuing a business his grandparents started over 50 years ago. He explains:<ul><li>Why short length of stay, not fraud, is the real crisis facing hospice today</li><li>How AI is helping nurses track and document patient decline more accurately</li><li>Why licensed practical nurse visits aren't reimbursed the same as registered nurse visits during a crisis, and why that's a problem</li><li>How respite and continuous home care are two of the most underused hospice benefits</li><li>Why bereavement care might be the most overlooked part of the entire hospice benefit</li></ul>Tom and Phillip also get into the CMS Hospice Care Index, the serving and spending variation index oversight framework, nursing home referral practices, de-prescribing medications near end of life, and what it's like building a family legacy in home health and hospice. Chapters:<ul><li>00:16 Intro</li><li>01:04 Philip's path into the family hospice business</li><li>03:38 About Saad Healthcare</li><li>04:50 A day in the life of a VP of Hospice</li><li>07:21 Inpatient hospice units: freestanding vs. hospital-based</li><li>09:50 Hospice under scrutiny in the national press</li><li>12:38 The 27% of hospices not submitting CMS data</li><li>17:21 Long length of stay and the SSVI framework</li><li>20:23 Using AI to track and document patient decline</li><li>23:10 Favorite AI tools in hospice care</li><li>24:01 Building a "hospice brain" to catch patients earlier</li><li>26:13 The $1.9 billion cost of choosing hospice late</li><li>28:20 De-prescribing medications near end of life</li><li>31:41 What respite care actually is</li><li>34:36 Continuous care in the home</li><li>37:01 Ad Break</li><li>39:25 The LPN vs. RN reimbursement problem</li><li>41:11 Why aides and chaplains don't count in CMS metrics</li><li>42:21 EMTs, paramedics, and the hospice workforce shortage</li><li>42:53 RN licensing caps and compact state frustrations</li><li>46:22 CMS's proposed rule and Medicare spending buckets</li><li>47:55 PTANs and the nursing home referral cap</li><li>51:36 Inside Saad's bereavement program</li><li>56:00 Text-based bereavement and community outreach</li><li>1:02:06 How to connect with Philip and Saad Healthcare</li><li>1:03:15 The legacy question</li></ul>Sponsors:<ul><li>Premier Sponsor: Homecare Homebase: <a href="https://hchb.com/" target="_blank" rel="ugc noopener noreferrer">https://hchb.com/</a></li><li>Maxwell TEC: <a href="https://maxwelltec.com/" target="_blank" rel="ugc noopener noreferrer">https://maxwelltec.com/</a></li><li>IntellaTriage: <a href="https://intellatriage.com/" target="_blank" rel="ugc noopener noreferrer">https://intellatriage.com/</a></li></ul>#hospice #homehealthcare #endoflifecare #hospicecare #medicare #HealthcarePolicy

July 9, 2026

CMS 2027 Proposed Rule Explained: What the 2.4% Increase Actually Means

CMS just proposed a 2.4% payment increase for home health in 2027. If that's the only number you take away, you're missing a lot.Tom Maxwell sits down with Jay Duty, COO at Maxwell TEC, to unpack what's actually happening underneath the headline: a temporary rate cut, a nearly $5 billion recoupment, a full case-mix recalibration, and provider enrollment changes that could put your Medicare billing privileges at risk.Jay spent his first ten years in the hospital business at HCA before moving into post-acute care strategy, eventually landing at Maxwell TEC. In this conversation, he and Tom walk through what CFOs need to know before they finalize next year's budget, why the "behavioral adjustment" methodology has the industry pushing back, and what a home health specific wage index could mean for high-cost and rural markets. Topics Include:<ul><li>The real math behind the 2.4% headline number and where it actually comes from</li><li>Why the temporary 3% clawback matters more than the payment increase</li><li>How to model your 2027 budget before the final rule drops in November</li><li>The CMS wage index proposal and its impact on rural and high-cost markets</li><li>What CMS's expanded provider enrollment authority means for your Medicare billing risk</li></ul> The comment period for this rule runs through August 31, 2026. If you're a home health agency owner, operator, or CFO, this episode gives you the framework to build your comment letter and your budget at the same time. Connect with Jay Duty: <ul><li><a href="jay@maxwelltec.com" target="_blank" rel="ugc noopener noreferrer">jay@maxwelltec.com</a> or <a href="https://www.maxwelltec.com" target="_blank" rel="ugc noopener noreferrer">https://www.maxwelltec.com</a></li></ul> Chapters:<ul><li>0:00 Intro: the 2.4% headline everyone's getting wrong</li><li>1:26 Jay Duty's path from HCA to home health strategy</li><li>1:53 The first thing Jay checks in a new CMS rule</li><li>2:21 What's actually driving the 2.4% number</li><li>3:55 The one sentence every CFO needs to remember</li><li>4:49 The behavioral adjustment, explained</li><li>6:26 Real example: therapy-only cases and the 30-day billing trap</li><li>7:44 The $4.9 billion recoupment breakdown</li><li>9:54 Is CMS's data methodology actually flawed?</li><li>12:15 What a strong industry comment letter argues</li><li>13:33 Why this rule always lands mid-budget cycle</li><li>14:46 How to model your 2027 budget starting now</li><li>17:01 Why visits per period keep falling</li><li>19:45 What investors and lenders should hear from you now</li><li>21:28 The case for a home health specific wage index</li><li>24:00 CMS's expanded power to deny or revoke enrollment</li><li>25:34 Can industry comments actually move the needle?</li><li>28:16 What makes a comment letter valuable to CMS</li><li>29:48 Will this adjustment mechanism still exist in five years?</li><li>31:51 What to do this week if you run an agency</li><li>33:08 How to reach Jay Duty</li></ul> Sponsors:<ul><li>Maxwell TEC: <a href="https://www.maxwelltec.com" target="_blank" rel="ugc noopener noreferrer">https://www.maxwelltec.com</a></li></ul>

June 29, 2026

From Valuation to Close: Inside the Deal Process for Home Health and Hospice Owners

What does it actually take to sell a home health or hospice agency, and how do you make sure you walk away with what your business is worth?Alex Veach, Partner at Agenda Health, joins Last Visit First for a conversation that covers the full arc of the healthcare M&A process, from the moment you start thinking about an exit to the day you close a deal. Agenda Health advised on roughly 25% of all home-based care transactions in 2025 alone, and Alex brings a decade of deal reps and hard-won market knowledge to every answer.This is not a theoretical conversation. It is a practical, direct look at how buyers evaluate agencies, what kills deals, how to time an exit around regulatory cycles, and why the emotional side of selling a business you built from nothing is just as important as the financial side. Topics include:<ul><li>What the current healthcare M&A market actually looks like for home health and hospice owners and where the opportunity is headed</li><li>The three things buyers prioritize above everything else in smaller agency deals and why compliance now leads the list</li><li>How Agenda's buyer profiling process matches sellers with the right capital partners, not just the highest bid</li><li>What the full deal process looks like step by step, from valuation call to signed LOI, for an owner who has never done this before</li><li>The emotional reality of selling a business you built from nothing and how good advisors help owners through it</li></ul>Chapters:<ul><li>00:00 Introduction to Alex Veach and Agenda Health</li><li>01:29 Alex's Background and Path to Agenda</li><li>02:45 What Agenda Health Does and Who They Serve</li><li>05:14 The Current M&A Market for Home Health and Hospice</li><li>07:43 What Most Owners Get Wrong About Valuation</li><li>09:18 Valuation Ranges Across Home Health, Hospice, and Personal Care</li><li>12:15 What a Platform Deal Actually Means</li><li>14:22 Buyer's Market or Seller's Market Right Now</li><li>17:34 How Large Platform Deals Create Add-On Opportunity for Smaller Agencies</li><li>19:05 Acquisition vs. Recapitalization: What's the Difference</li><li>21:37 The Top Three Things Buyers Look for in Smaller Agencies</li><li>25:12 The Role of Team and Key Man Risk in a Deal</li><li>26:39 How Regulatory Timing and Rate Changes Affect Deal Process</li><li>29:22 Ads</li><li>31:59 Building Relationships and Teaching the Business</li><li>36:47 How Long the Seller Relationship Takes to Develop</li><li>39:33 Begin With the End in Mind: Prepping 24 Months Out</li><li>42:01 EMR Data, Financial Readiness, and What Buyers Are Testing</li><li>45:42 Walking Through a Real Deal: 250-Patient Hospice in Houston</li><li>46:27 Valuation Presentation and Process Strategy</li><li>49:46 Ads</li><li>50:51 The Data Room: How It Works and Why It Matters</li><li>53:03 Keeping Census Up While Your Deal Is in Process</li><li>56:46 Managing Team Distraction and Confidentiality During a Sale</li><li>58:01 Legacy, Impact, and What Alex and Agenda Want to Be Known For</li><li>1:03:39 The Emotional Reality of Selling Your Business</li><li>1:04:37 How to Reach Alex Veach and Agenda Health</li><li>1:05:46 Closing Thoughts</li></ul>Connect with Alex Veach and Agenda Health:<ul><li>Agenda Health's Website: <a href="https://www.agendahealth.com" target="_blank" rel="noopener noreferer">https://www.agendahealth.com</a></li><li>Agenda Health's LinkedIn: <a href="https://www.linkedin.com/company/agenda-business-services/" target="_blank" rel="noopener noreferer">https://www.linkedin.com/company/agenda-business-services/</a></li><li>Alex's LinkedIn: <a href="https://www.linkedin.com/in/alex-veach" target="_blank" rel="noopener noreferer">https://www.linkedin.com/in/alex-veach</a></li></ul>Last Visit First:<ul><li>Apple Podcasts: <a href="https://podcasts.apple.com/us/podcast/last-visit-first/id1830051182" target="_blank" rel="noopener noreferer">https://podcasts.apple.com/us/podcast/last-visit-first/id1830051182</a></li><li>Spotify: <a href="https://open.spotify.com/show/3iSKGRvHC9Bk3iq7l8UPxs" target="_blank" rel="noopener noreferer">https://open.spotify.com/show/3iSKGRvHC9Bk3iq7l8UPxs</a></li><li>YouTube: <a href="https://www.youtube.com/@lastvisitfirstpodcast" target="_blank" rel="noopener noreferer">https://www.youtube.com/@lastvisitfirstpodcast</a></li><li>Website: <a href="https://www.lastvisitfirst.com" target="_blank" rel="noopener noreferer">https://www.lastvisitfirst.com</a></li><li>LinkedIn: <a href="https://linkedin.com/company/last-visit-first" target="_blank" rel="noopener noreferer">https://linkedin.com/company/last-visit-first</a></li></ul>Sponsors:<ul><li>Premier Sponsor: Trella Health: <a href="https://trellahealth.com/" target="_blank" rel="noopener noreferer">https://trellahealth.com/</a></li><li>Premier Sponsor: Homecare Homebase: <a href="https://hchb.com/" target="_blank" rel="noopener noreferer">https://hchb.com/</a></li><li>Maxwell TEC: <a href="https://maxwelltec.com/" target="_blank" rel="noopener noreferer">https://maxwelltec.com/</a></li><li>StenoHealth: <a href="https://www.stenohealth.com/" target="_blank" rel="noopener noreferer">https://www.stenohealth.com/</a></li><li>IntellaTriage: <a href="https://intellatriage.com/" target="_blank" rel="noopener noreferer">https://intellatriage.com/</a></li></ul>

46 total episodes available

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Frequently asked questions

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What is Last Visit First?: Most care stories in home healthcare end with the last visit. Last Visit First podcast starts there.

Hosted by Tom Maxwell — a nationally respected healthcare veteran with over three decades of experience, Co-Founder and Chairman of Maxwell TEC, Maxwell Investment Partners, and Maxwell Advisory Group — this podcast features honest, unfiltered conversations with the founders, CEOs, clinicians, and innovators shaping the future of home health, hospice, palliative, and post-acute care.

If you lead, operate, or believe in the power of care in the home, this is your podcast. Subscribe to listen.
How often does this podcast release new episodes?: This podcast updates daily.
Where can I listen to this podcast?: This podcast is available on 4 platforms including Apple Podcasts, Spotify, and more. You can also use the RSS feed directly.
Does this podcast accept guests?: Yes, this podcast regularly features guests.

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