Lessons from Amar Kendale, Cofounder and President of Homeward, on Addressing Care Gaps in Rural Health
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Today we're grateful to get to know Amar Kendale, Co-founder and President of Homeward, a company reinventing how care is delivered in rural America. Amar has spent the last 20 years building healthcare products that make life better for patients, providers, and health plans. At Homeward he is focused on improving access to care in rural communities. Before that, he helped grow Livongo from an early-stage startup to its $18B acquisition by Teladoc, where he became Chief Product Officer.
In this episode, we’re diving into how Homeward started, the challenges in building in rural health, how Homeward operates and gets paid, and how the company hopes to scale and navigate the upcoming year.
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How Homeward Started
Amar Kendale and Dr. Jennifer Schneider are the co-founders of Homeward Health, a company launched in 2022 to rebuild care delivery for people living in rural America. Their partnership and the vision behind Homeward began years earlier.
The two first worked together at Livongo, one of the earliest and most influential digital health companies focused on chronic disease management. Amar joined Livongo in 2014, just after its Series A, when the company was focused on helping people manage diabetes. At the time, diabetes care was largely reactive and fragmented. People were left to manage their condition on their own, often resulting in preventable complications, emergency department visits, and hospitalizations. Livongo’s bet was that a combination of smart technology, behavioral science, and ongoing support could empower patients to take control of their health.
Jenny joined Livongo about a year later as Chief Medical Officer. She brought deep expertise as a physician, health services researcher, and entrepreneur. Together, Amar and Jenny worked to bridge the gap between clinical rigor and product innovation. Their collaboration helped expand Livongo beyond diabetes into other chronic conditions, including hypertension, heart failure, and behavioral health. The company grew rapidly, went public in 2019, and was acquired by Teladoc in 2020 for $18.5 billion. At the time, it was the largest digital health acquisition ever completed. Jenny had become President of the company, and the two had built a strong foundation of trust and complementary leadership.
After the acquisition, Amar and Jenny began thinking about which problems in healthcare remained unsolved and what they wanted to focus on next. They received many offers to build a “Livongo for X” across various conditions, but none felt compelling enough to pursue. Jenny joined General Catalyst as an Executive-in-Residence, a role designed to help experienced leaders incubate and launch new ventures. The two reunited to explore a new idea that felt both mission-driven and essential.
They looked across the healthcare landscape and focused on a few core principles. They wanted to address a large and underserved population. They believed technology needed to be essential to the solution. And they looked for models that aligned incentives, ideally through value-based care.
That focus led them to rural health.
People living in rural America experience more than 20 percent higher mortality rates than those in urban areas (CDC). In some cases, outcomes were worse than in low-income countries. Geography often determines access to care, and the existing system was leaving rural communities behind.
In 2022, they launched Homeward to redesign healthcare for these communities. Their model combines in-person visits, virtual care, remote monitoring, and value-based contracts.
The Challenge of Building in Rural Health
According to the CDC, rural residents face higher rates of heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Access is a major issue: over 180 rural hospitals have closed since 2005 (source), and many communities lack reliable access to primary care, mental health services, or specialists. Transportation barriers, workforce shortages, and broadband limitations further compound these challenges.
The causes of these disparities are complex and long-standing. Amar points out that rural Americans are not a monolithic group. They span every political affiliation and geographic region, which makes it clear that no single factor is responsible for the health gap. Instead, the issue stems from a combination of structural, economic, and geographic barriers that have built up over decades.
One of the biggest challenges is physical distance. Rural populations are spread out, while healthcare infrastructure has historically been centralized in order to operate efficiently. Hospitals, equipment, and clinicians/staff are typically concentrated in urban hubs to ensure high utilization. As a result, rural patients often live hours away from the nearest care facility. This creates significant barriers to accessing care, especially preventive services.
“You can imagine, as a person, doing the calculus in your own mind, do I really want to drive two hours, sit in a waiting room with sick people, have the doctor run a bunch of tests, and then be told I’m fine, even though I already feel fine? All that effort for that answer just doesn’t feel worth it. It’s a lot of work for not a lot of benefit. Very different story if it’s a 15-minute drive, no wait, and it doesn’t cost you anything. That idea of behavioral ROI or the return on effort just doesn’t really work out in rural settings.”
This dynamic leads to a second problem: over time, many people in rural communities have learned not to expect much from the healthcare system. Preventive care becomes deprioritized, and demand for services decreases. As a result, rural healthcare has become largely reactive. People often delay seeking help until their conditions are more severe. Emergency departments are frequently used as a substitute for primary or urgent care because they are the only accessible option. This leads to higher hospitalization rates, longer lengths of stay, and more advanced disease at the time of first contact.
While distance and infrastructure are core issues, rural healthcare faces several other deep-rooted challenges:
Fewer providers across all levels of care, including primary, specialty, and mental health
High rates of uninsurance and underinsurance, discouraging early care-seeking
Stigma surrounding mental health, despite rising suicide and depression rates
Aging populations with few local caregiving or long-term care options
Underfunded public health systems, limiting prevention and outreach capacity
Higher levels of poverty and food insecurity, compounding health risks
How Homeward Fits Into Rural Health
Before building Homeward, the team asked a fundamental question: Have traditional strategies for improving rural healthcare actually worked? The answer was clearly no.
Here are a few of the most common approaches and why they’ve fallen short:
❌ Recruit more doctors
Financial incentives and loan repayment programs have tried to bring more physicians to rural areas. But they haven’t solved the deeper issues. Many providers are reluctant to relocate due to limited professional support, fewer opportunities for spouses, and lack of educational infrastructure. The workforce shortage remains.
❌Keep rural hospitals open
There’s been a push to sustain rural hospitals by increasing reimbursement or providing emergency funding. But most of these facilities are designed for high-acuity, inpatient care, not for preventive or chronic disease management, which is what rural populations need most. Without volume to cover high fixed costs, many hospitals remain financially unstable.
❌Pay providers more
Raising payment rates doesn’t fix the fact that care is still hard to reach, inconvenient, and often fragmented. Better reimbursement doesn’t equal better access or trust.
Homeward started by asking rural patients what actually matters. Three consistent themes emerged:
Be from the community: Patients are more likely to engage when care comes from people who understand them.
Make it easy: Time, transportation, and complexity are real barriers.
Don’t charge me: Even small out-of-pocket costs stop people from showing up.
Homeward designed its care model around those realities. Their teams include community health workers and medical assistants, hired locally and trained to operate at the top of their scope. These team members build trust, connect patients to local resources, and help people navigate the system.
Transportation is a common barrier. Many rural residents don’t have a way to get to appointments and public transit is rare. Homeward’s teams identify county-run vans, ride shares, or aging center shuttles and link patients to them, resources that often already exist but go unused.
In some areas, they partner with local primary care practices. Providers often ask Homeward to handle routine tasks that are time-consuming, poorly reimbursed, or lower acuity. This allows doctors to focus on sicker patients and more complex care.
As one provider put it, they are already seeing patients from 7 a.m. to 7 p.m. They do not have time to track down the people who are not showing up, even though those patients could benefit from preventive care. Homeward steps in to fill that gap and works closely with local clinicians to make sure everything is documented and coordinated. The goal is not to replace primary care but to make it more sustainable.
In other areas, there may be no active primary care presence at all. Roughly 30 percent of Homeward’s patients have not seen a doctor in over a year. For those patients, the first step is understanding where they are in their care journey and how open they are to re-engaging.
Sometimes, Homeward provides primary care directly. For frail or homebound patients, that might mean in-home visits, screenings, or prescriptions. The aim is to stabilize the patient, address immediate needs, and then help them transition to a longer-term primary care home. If that takes time, Homeward continues to provide care in the interim to keep patients safe and supported.
Business Model of Homeward
Homeward’s business model focuses on value-based care, which is a principle that aligns incentives for all stakeholders in the healthcare ecosystem. Payers are motivated to maintain population health, leading to lower downstream costs. Providers gain economic incentives linked to positive outcomes, often financial but also quality-driven. For patients, this model translates to reduced out-of-pocket expenses and improved health outcomes.
However, the adoption of value-based care models in rural America has been notably slow, lagging significantly behind urban and suburban settings. Several factors contribute to this lag:
Limited Payer Leverage in Thin Networks: Rural healthcare networks are often sparse, which diminishes the leverage payers have to incentivize providers into value-based arrangements. Unlike more congested markets, rural areas offer fewer alternatives for payers.
Rural Provider Preparedness and Infrastructure Deficiencies: Many rural healthcare providers lack the necessary infrastructure investments to effectively operate within a value-based care framework. This includes essential capabilities for data analysis, population health management, and proactive clinical interventions, all of which are vital for successful value-based models.
Homeward Health has developed a strategic approach to address these gaps by positioning itself as a direct value-based care provider, employing a vertically integrated model without stealing attribution from the rural physicians.
Homeward's model begins with direct partnerships with payers. They identify specific populations with unmet healthcare needs and adopt a full capitation model for these groups. This involves multi-year contractual relationships with payers, with the objective of transitioning to full financial risk over a relatively short period.
Under a full capitation arrangement, Homeward negotiates a fixed per-member, per-month payment for a defined patient population. From that point, Homeward assumes all financial risk – both upside and downside. This structure places Homeward directly responsible for running a population health model that drives improved outcomes and reduces costs over time. The reduction in healthcare costs for the population directly translates into Homeward's margin and profit, ensuring strong incentive alignment with patient needs and payer objectives.
The financial structure of full capitation provides Homeward with the flexibility needed to implement its comprehensive population health model. Key components include:
Population Stratification: Identifying individuals within the target population who have the highest healthcare needs.
Proactive Resource Allocation: Directing clinical and supportive resources to these high-need individuals.
Utilization of Fast-Moving Data: Unlike traditional models that rely on slow-moving claims data, Homeward leverages more immediate data points, such as admission, discharge, and transfer (ADT) data, as well as medication data. This enables proactive interventions and allows Homeward to anticipate and mitigate negative health trends.
This direct engagement with payers and sophisticated population management capabilities form the core of Homeward's vertically integrated ecosystem. This approach facilitates significant investments in data infrastructure and clinical models tailored to drive outcomes, particularly for the Medicare Advantage population. The model is currently caring for over 100,000 patients in Michigan, demonstrating its scalability across diverse rural environments, from frontier regions requiring significant geographic travel for care, to exurban areas where access remains limited.
Homeward's model is designed to be complementary, not competitive to physician practices. They explicitly address concerns about "attribution" – the process of linking patients to primary care providers for financial purposes – assuring local providers that Homeward is not seeking to take their patients. Instead, the aim is to "preserve and nurture" existing patient-provider relationships and to augment them with supportive services.
Scaling the Impact of Homeward
The scalability of Homeward Health's model across diverse counties and states is a critical aspect of its operation, notably demonstrated by its presence in Michigan and Minnesota. While initial efforts deeply focused on local engagement to understand specific populations and resources, Homeward has increasingly identified significant opportunities for virtual care delivery, particularly in resource-scarce regions. A core component of this scaling strategy involves empowering advanced practice providers (APPs), like nurse practitioners and physician assistants, to practice at the top of their credentials. A substantial portion of this APP workforce is hired virtually, delivering care in tandem with local teams.
A typical Homeward home visit illustrates this hybrid approach:
A local navigator, equipped with a tablet and satellite connection (e.g., Starlink), conducts the initial part of the visit. This includes building trust, performing assessments, and discussing community resources and benefits navigation.
Approximately 15 minutes into the visit, a remote APP joins virtually. This remote provider is well-positioned to develop an effective treatment plan, leveraging the data collected by the navigator.
The virtual interaction ensures a warm handoff, as the patient has already established trust with the navigator. The APP provides about 15 minutes of virtual care.
The navigator then closes out the visit, addressing "last mile problems" such as arranging local pharmacy pickups or mail-order prescriptions to ensure the treatment plan is actionable and adhered to.
Addressing the rural healthcare workforce crisis is another critical aspect. Rural providers are, on average, a decade older than their urban and suburban counterparts, leading to a significant wave of retirements that will exacerbate existing shortages. Homeward's strategy acknowledges that relying solely on physically located rural primary care doctors is unsustainable. Therefore, "upskilling" becomes a powerful concept, empowering mid-level and entry-level clinical professionals who are often deeply committed to their local communities. Technology plays a crucial role here; generative AI, in particular, is seen as transformational for handling unstructured information and providing real-time guidance and decision support.
The effectiveness of Homeward's work in scaling care and transforming the rural workforce is clearly measurable. Patient satisfaction is a primary indicator, with Homeward achieving Net Promoter Scores (NPS) above 80. To put this in context, the average NPS for healthcare companies typically ranges between +38 and +58, and a score of 70 or higher is generally considered "world-class." Homeward's NPS above 80 reflects exceptionally high levels of trust and positive patient experience.
Another crucial outcome metric is the reduction in emergency department (ED) utilization, meaning fewer avoidable trips to the ER for critical patients. Homeward has demonstrated an 8% reduction in ED utilization within its first year of fully scaled service delivery for its high-needs patients. This impact is often linked to addressing social determinants of health factors, underscoring Homeward's holistic approach.
Future of Homeward: Medicaid, Policy, and Sustaining Rural Care
Homeward Health's journey is seen as a long-term build, not a quick flip. The core thesis remains transforming rural healthcare and fixing a broken system, a mission that extends beyond specific markets or segments. Looking ahead, Homeward envisions deeper integration within rural healthcare ecosystems, touching more participants and offering diverse support. The model is already diversifying, moving beyond strict value-based care to include "pathway to value" models and even fee-based services focused on administrative performance.
A potential part of Homeward's future lies in expanding into Medicaid, a population with a substantially higher proportion of rural Americans compared to urban or suburban communities. This is particularly critical now that the Big Beautiful Bill has passed. While it includes a historic $50B Rural Health Transformation Fund, it also enacts sweeping cuts to Medicaid, an estimated $793 billion to $880 billion over the next decade (source), according to the Congressional Budget Office. These reductions represent a significant blow to coverage and will intensify financial pressures on rural providers, many of whom already operate on razor-thin margins. Homeward views the rural fund as a once-in-a-generation opportunity, but only if it’s used to drive structural transformation, not just backfill budget gaps.
Although the law includes a $50 billion Rural Health Transformation Fund, this offset covers only about a third of expected Medicaid losses in rural areas and just 5 percent of overall Medicaid cuts. The fund’s temporary nature, lack of guaranteed targeting to high-need areas, and limited transparency in distribution further dilute its potential impact.
For Homeward, the fund is a once-in-a-generation opportunity to support structural transformation, but only if states and CMS use it effectively. States will have wide discretion in how funds are allocated, and CMS has broad authority in evaluating applications. As a result, the fund’s impact will vary widely depending on state policy choices and federal oversight. Even so, the environment is pushing stakeholders toward scalable, tech-enabled solutions, areas where Homeward has already built strong capabilities.
The silver lining lies in the power of modern technology, including generative AI, automation, and advanced data infrastructure. Medicaid populations are typically younger and tend to adopt technology more quickly, making them more comfortable with digitally enabled care models. While full capitation models might not be immediately feasible in the Medicaid space, Homeward is positioning itself to partner with Medicaid plans, offering solutions that align with outcomes and patient satisfaction, while leveraging modern technology to serve these hard-to-reach populations.
Interested in Homeward? Learn more on their website, X, and LinkedIn
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Very informative