Alexander (Xander) Page is the CEO of Trusted Ally Home Care, a home healthcare agency he built to provide the specialized care many former Department of Energy workers need. Since its founding in 2011, Trusted Ally Home Care has reached over $10 million in top-line annual revenue—20% of which can be attributed to the agency’s first acquisition. I recently spoke with Xander and his Director of Finance, Hayden Brink, about why the company has chosen an “admittedly small” niche, how strategic acquisitions opened the door to growth, and why M&A is a pivotal part of Trusted Ally’s future as an owner-operated enterprise.
Passion Meets Profitability
In 2011, Xander Page was a soon-to-be MBA graduate who wanted to build a mission-driven company. His education laid the groundwork for Trusted Ally Home Care’s success, but the agency’s purpose reaches back to the 1950s, when his now-wife’s grandfather, Johnny, worked as an ironworker at a Department of Energy nuclear testing site in Nevada, California.
Johnny was regularly exposed to radiation as part of his work, the levels of which were measured by his dosimeter badge. In theory, if the badge indicated high levels of exposure, work would stop until the environment was clear. In practice, workers would swap out for a fresh badge and keep working until they were told to go home and “flush the radiation out” with a six-pack of beer.
After decades of exposure to radiation, Johnny and workers like him faced cancer and other devastating illnesses. They fought hard and won a lawsuit for healthcare benefits through a special program established by the Department of Labor.
“The worker population count, anecdotally, is huge,” Xander says. “We don’t have an exact count, but we’re talking 100,000 plus people who participated in this [Department of Energy] program from the 1950s on.”
Xander heard how round-the-clock care gave his wife’s grandfather dignity in his final year of life. He also came to understand the unique challenges faced by workers like Johnny – navigating bureaucratic and complicated benefits systems while managing their health care. This was the genesis of Trusted Ally Home Care.
Building Momentum With Acquisition
Despite the large population of workers, Xander quickly realized that the market is “very stratified.”
“There are five big companies that do ten times what we do. There are maybe 40 mom-and-pops. Then, there are maybe three or four other mid-level growth companies like ours. So, for us, it feels like there’s a lot of opportunity,” Xander explains.
That opportunity meant not only capturing new markets but improving the quality of care for the worker community. But growing organically was proving challenging, largely because hiring enough home health workers required massive outlays of time and resources. In March 2020, Xander went looking for help and found Hayden Brink, Trusted Ally’s now-Director of Finance. In an initial meeting, Hayden pitched Xander some ideas for the agency’s expansion. M&A was at the top of that list, given his early career experience in sell-side investment banking.
“I certainly think that in terms of being able to grow revenue 20 to 30% in one hit, it’s a lot faster to do an acquisition than it is to build organically,” Hayden says, “and the ROI can still be there.”
From then on, Xander and Hayden had a two-man M&A team, but they learned that their limited niche would uniquely challenge the deals they planned.
“Relative to the deals that come across our desk, it’s absolutely very low volume,” Xander says, “and it does make finding a company to buy much harder.”
Target Criteria
Despite the limitations of their niche, Hayden and Xander carefully defined what they considered an ideal acquisition: agencies that added value to Trusted Ally and that Trusted Ally could add value to in return.
Specifically, they focused on agencies serving the former worker population that had:
- Geographic Alignment, meaning that the target agencies were located in areas that both had a high population of former workers and aligned with Trusted Ally’s expansion goals.
- Favorable Patient Concentration in the payment sources. Hayden analyzes whether the target agency’s patients have 100% Department of Labor-paid benefits, Department of Labor-forward benefits, or mixed private and public payment.
- Exceptional Talent that would expand Trusted Ally’s capabilities. As Hayden puts it, “If we can make an acquisition and get a lot of great talent, that’ll really help us grow.”
- Existing Licensure, particularly in states with a high barrier to entry.
Making the First Deal
In Grants, New Mexico—called the Uranium Capital of the World—two nurse owner-operators had built a successful home care agency. Like Trusted Ally, they cared for former Department of Energy workers, including miners and millers who suffered serious illnesses after years of jackhammering uranium in underground caves.
For the nurses, their work was personal. That made this acquisition a story of right place, right time, and right reputation.
“From their perspective, we were the best fit due to not being one of the big agencies that lack deep compassion for their patients, but we also had the balance sheet to write them a check,” Hayden says.
The deal took six months to close after sending the letter of intent, much longer than the 90-day window the average merger requires.
They closed in June 2021, and Trusted Ally Home Care recouped their investment in just 18 months, retaining nearly every patient and the agency’s entire 40-person workforce. The acquisition netted Trusted Ally Home Care $2 million in annual revenue in a town of 10,000 people and 40% growth in top-line revenue at the time of the acquisition.
“It was an awesome deal to cut our teeth on. The challenge was out of state, COVID, two nurse operators who knew they wanted out,” Xander says. “I think we created an outcome that was equitable.”
As successful as the deal was, it also laid the groundwork for the many mergers Xander and Hayden have planned for Trusted Ally’s future.
Expanding Beyond the Niche
Xander says he’s fortunate to receive countless unsolicited letters of intent. For now, he’s turning them all down.
“I’d love to own this business until the last nuclear worker is served,” Xander says.
To do that, Xander and his leadership team are ramping up for a three to five-year cycle with one goal: growth.
“Where we want to go is ten times where we are in ten years or less,” Xander says. “In our niche alone it would be a little tough. Outside of it is what we have our eyes on.”
Xander explains that while they will continue to focus on the former worker population, they’re also eyeing opportunities to acquire licensed traditional home health agencies to which they can add their more niche care options.
“Doing deals is very exciting. If we can grow through the right purchase, it gives us access to new markets and new patients,” Xander says. “The thesis that we had about being able to come onto existing patient cases and add value to them still holds. We just need to be more proactive in relationship building because the target set is so small.”
Lessons Learned
Xander knows that the business development lessons they learned through their first deal will inform how they approach acquisitions moving forward. Their lessons are also valuable for any other founder considering acquisitions as a growth driver.
1. Quickly establish a sustained presence.
The first big lesson was a simple one: get on-site faster. “The big learning I would share with anyone who ends up reading this case study is we did not get down there with enough of a sustained presence in the first three months to affect any change,” Xander says.
Though they based the strength of the deal on being able to bring Trusted Ally’s processes and procedures to New Mexico, they lacked the systems – and relationships – to effectively realize that vision.
Hayden points to electronic documentation as an example. All of Trusted Ally’s caregivers use tablets to electronically document patient files. In New Mexico, all that work happens on paper, and some of the caregivers pushed back against electronic documentation because they lacked Wi-Fi and in some cases even cell service.
“We bent a number of our systems to accommodate the population,” Hayden says.
Though Hayden and Xander agree they would do the deal over again, they will take a different tack for future acquisitions—and advise that fellow founders do the same.
2. Create an acquisition playbook.
Xander and Hayden also acknowledge that having repeatable processes would have helped iron out some of the kinks in their first deal. “We didn’t go down and have a clear playbook for what Trusted Ally’s process looks like,” Xander says.
As a result, they deferred to the homegrown processes the nurse owners had developed. Moving forward, Xander and Hayden plan to develop a playbook for how Trusted Ally will mobilize their approach in a new locale.
They suggest other business owners do the same to avoid perpetuating what could be a less effective status quo. But according to Hayden, it’s not about bringing down the hammer. It’s about making the change exciting for the inherited workforce, promoting buy-in through swag, improved benefits/pay, ongoing training, and a consistent presence.
“We didn’t have any relational capital to go in and create change,” Hayden says. “There was no leverage, so we just accepted the status quo until recently.”
3. Approach M&A as relationship building.
Hayden and Xander are gearing up to make more deals. But given the size of their niche, they know that making successful deals is about building relationships.
“How do we stay in touch with people, how do we add value to them, how do we show them who we are,” Hayden says. “Being structured will certainly pay dividends over the long term.”
What will that look like in practice? Becoming the preferred buyer for smaller agencies in former worker home health care and beyond.
“Having the awareness and the right to choose is what we want,” Hayden says.
About the G-Spire Group
The G-Spire Group helps companies grow through strategic mergers and acquisitions. As a fractional executive, we roll up our sleeves to help management teams drive growth through M&A, supporting key activities such as strategy, outreach, deal structuring and valuation, due diligence, capital structuring and integration. To learn more, please visit: https://www.gspiregroup.com/