Caregiver, Inc. Raises the Bar, Continually Measures Service Delivery, Immediately Resolves Concerns

(Fort Worth, Texas) – In caring for individuals with intellectual and developmental disabilities (IDD), states across the country require that service companies annually survey their clients and guardians. Historically, IDD providers mailed a paper-based survey each year with little hopes of receiving a response. Issues and concerns would go unchecked, minor annoyances would compound, and satisfaction went unmeasured. To Fort Worth-based Caregiver, Inc., this was not good enough for the individuals they served. How could they do better and ensure their care was meeting their individuals’ needs? The answer: real-time surveying and Net Promoter Score®.

In 2018, the Caregiver executive team determined that it was time to raise the bar on measuring their quality of service. The company engaged Cleveland-based Direct Opinions to develop a call-based surveying, alert, and measurement strategy for gauging their performance and the satisfaction of their individuals’ guardians.

“While the rules state that we have to attempt to survey once annually, we wanted to look at ways we can improve our services and our communications with guardians, solicit feedback about what’s important to them, and serve our individuals the best we can,” said Alex Sturges, Vice President of Operations Strategy. “We ultimately want to be better providers and respond to any issues in real time; we invested in our survey program to help us to do just that.”

With their new program, Caregiver surveys their individuals’ guardians in Texas and Tennessee, and the company has plans to expand the program to their other states, such as Ohio and Indiana. For now, the company receives an average of approximately 70 responses per month on 200 calls for a 35% response rate, which is about double their historical response rate. The company receives an average of four Concern Alerts – an issue that needs to be handled quickly – per month, which are all addressed within a few days.

“The transition from paper-based surveys to call-based and Net Promoter Scoring is transformative,” said Mr. Sturges. “We can see trends, how different geographic areas compare to others, listen to call recordings if needed, and more. There’s tremendous value for us to have this level of insight, and, more importantly, our guardians feel like they are truly heard.”

How It Works

Instead of an annual paper-based, mailed survey, Caregiver now employs Direct Opinions to call their Texas and Tennessee individuals’ guardians a minimum of two to three times per year, and they will continue attempting to connect with them unless specified otherwise. Caregiver and Direct Opinions co-wrote the call script to ensure quality data is collected. The guardian is surveyed on their experience with Caregiver and its companies, and they are asked the Net Promoter Score® (NPS®) customer experience question: “how likely is it that you would recommend Caregiver to a friend or colleague?” Respondents give a rating between 0 (not at all likely) and 10 (extremely likely) and, depending on their response, customers fall into one of three categories to establish an NPS score:

  • Promoters respond with a score of 9 or 10 and are typically loyal and enthusiastic customers.
  • Passives respond with a score of 7 or 8. They are satisfied with the service but not happy enough to be considered promoters.
  • Detractors respond with a score of 0 to 6. These are unhappy customers who are unlikely to work with the company again and may even discourage others from engaging with Caregiver.

The NPS is then calculated by percentage of promoters minus percentage of detractors times 100. A score above zero is positive, 50 is excellent, and Caregiver’s NPS score is currently 32.

As well, in the course of the phone interaction, if the caller hears anything that requires attention and follow-up, the caller will create a “Concern Alert”, for which Caregiver instituted a requirement for these alerts to be acted upon within 24-48 hours.

Concern Alerts

In addition to the calls Direct Opinions makes on Caregiver’s behalf, the company also developed a dashboard that Caregiver logs into to monitor survey results and Concern Alert actions.

“Our new survey system has brought to light a few issues – ‘Concern Alerts’ – but the good news is that we are able to act on them immediately,” said Mr. Sturges. “When we receive a Concern Alert, the Area Director of the region where the individual is located is notified, and they are tasked with immediately calling the guardian to rectify the situation.”

A few examples:

  • In San Antonio, a survey call revealed that a parent who used to see their son every week had not been able to get together for over a month. With the Concern Alert, the Area Director both arranged an outing within 48 hours, as well as ensured that this priority remained on the individual’s group home list of needs and wants.
  • In San Angelo, a guardian alerted the surveyor that they were concerned about their immobile individual spending too much time in bed. He used to have a recliner in the living room, which enabled him to get out of bed during the day and interact with others in the living room of his group home, but, at some point, the recliner disappeared. Caregiver quickly purchased a new recliner and trained the staff on moving the individual to and from the bed and recliner.
  • In Houston, a guardian conveyed that she didn’t feel like she was being communicated with in a timely manner. She was given the Area Director’s contact information, the entire team was trained on communication, and the guardian received a direct number she could use if she ever felt like she needed any updates on the individual’s care, medications, etc.
  • In Dallas, a guardian felt that a medical bill was outstanding. Caregiver ensured that payment was made that week, and that the guardian was in the loop about payment status.

Additionally, Area Directors are trained to review the Caregiver survey dashboard and connect with any “detractors” regardless of whether there was a specific concern alert.

“A score of 0 to 6 is a clear call for help even if there isn’t a specific concern mentioned,” said Mr. Sturges. “It’s obvious something isn’t right, and we need to address whatever it is immediately.”

Terri Willingham, Compliance and Quality Coordinator, agrees, and adds that having a neutral party ask questions can help reveal both positives and negatives more readily.

“Our survey program exemplifies that we treat each individual as a unique person with their own specific needs and goals,” said Ms. Willingham. “We are conscientious and truly want to know what their experience is like so that we can continue apace or make necessary corrections. Whereas a paper survey could take a year to come back to us, with continual surveying we can take immediate action.”

Key Learnings and Actions

As with the Dallas-area guardian concerned about timely bill payment, Caregiver learned that matters relating to money are highly correlated with their Net Promoter Score. In fact, negative feelings regarding Trust Fund performance can have an outsized impact on the company’s NPS.

Between the NPS responses and specific Concern Alerts, Caregiver realized that there was room for improvement in their Trust Department. First, they hired a representative payee and eligibility manager to manage the process, create more structure around the department, and improve the service level. Then, they invested in more training, processes and procedures, as well as cross-training between different functions to help their team see the larger picture.

“Once everyone understands their role more clearly within the entire ecosystem, job performance improves,” explained Mr. Sturges. “Tasks are completed more readily and more accurately now, such as correct payment flow.”

Caregiver also converted many of their regions from a paper-based system to a software called Resident Fund Management Service, which helps ensure Caregiver is a good steward of their individuals’ funds received from Social Security or their families. The individual has access to their weekly allowance, bills are paid, room and board agreements are satisfied, and guardians can trust that everything is handled appropriately and in a timely manner.


Caregiver has plans to continue to expand and evolve their survey program to ensure they reach every individual served in every region the company has a presence.

“It’s not easy to hear that someone is upset or that there’s room for improvement,” concluded Mark Lashley, CEO of Caregiver. “But this business isn’t about our comfort; we are here to ensure every individual in our care is receiving the best service possible to help them reach their respective goals and live their best lives. If we don’t ask questions, we won’t get the answers we need to serve those who trust us with their care. The data we collect, measure, and act upon is critical to our mission.”




Caregiver, Inc., is a privately held company with 4200 employees within the headquarters support group and branded affiliate organizations in four states. The affiliates provide intermediate, home and community care services to over 3000 individuals who qualify as developmentally or intellectually disabled or are impacted by related conditions. Caregiver, Inc. was formed in 2015 and now includes these affiliates:  Unified Care Group, Southern Concepts; River Gardens; Daybreak Community Services Inc.; St. Giles Living Centers; Mosaic; DSA of Indiana; CG-HHC; All Care Services; T/R Residential; S&K of Canton, Ohio; and Omni Support Services of Tennessee. All have similar service offerings and strong reputations in their local communities. Caregiver services include supported home living, family protective services, case coordination, nursing services, respite services, day habilitation, psychology services, dental treatment, specialized therapies, adaptive aids, minor home modifications, and supported employment. Caregiver president and CEO is Mark Lashley. Company headquarters are at 4800 Overton Plaza, Suite 440, Fort Worth, Texas 76109. Phone is (800) 299-5161. They are on the web at



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