Researching Switching Gears to HHC - Entrepreneural Route

LoisJean · Dec 18, 2002

:kiss Agnus, this kiss is for you! What you want to do is exactly my idea of what the essence of a self-employed nurse needs to be...get out there and serve the ones who most need it!

I also understand what you're feeling regarding payment options. I, too, live in a rural area. Per capita, the county I live in holds the distinction of having the highest percentage of welfare receipients in my State, (and also the highest number of alcoholics -per capita.) We also have a high number of elderly in my area. Many of these folks are women whose husbands are deceased and they are living on nothing more than a small social security check each month--no pension, no other provision. When I started out 7 years ago-on my own- I charged a flat rate of $12.00 per person!! Good friends and family told me I was insane!! Well, maybe...but, it got my foot in the door--and once people found the care to be very good, they wanted me back again...little by little I began to raise my rates. Some folks dropped off, but most of them stayed on and recommended my services to their families and friends...then they began telling their docs about it. I have only advertised my services once and that was when I first started out: Licensed Nurse Provides Foot Care For You In Your Home". It ran for three days.

Since I have never been privvy to the balance in anyone's check book, I had to start out with a figure that might have seemed ridiculously low, but in time could be increased. (and, I kept my 'day job' for a while).

I provide foot care now at a charge of $20.00 per person- out of pocket. I now increase my charges in increments of $5.00-every two years on my business anniversary...next July my out of pocket charges will be $25.00 per person. (I use my own, "secret formula" to gage my increases by- but, I will share it if anyone is curious). I do have a contract with a Medicaid Waiver Program- (Home and Community Based Services) and I see these folks each month and bill $37.50 per person for the care. That billing is sent into the contracting Medicare Agency and they process it through Medicaid--(I receive monthly check from the agency.) There has GOT TO BE a Medicaid Waiver program in your area, honey! No area as needy as yours is without a system of welfare of some kind.

You have to start somewhere, Agnus. I can really sense that you are chomping at the bit something fierce! Like Bonnie says: don't give up your day job just yet, but maybe start pounding on some doors on days off or on weekends. Contact your State's Welfare Provider; tell a doctor or two what you want to do...see if they can give you a 'leg up'. Put a small ad in the local paper. Talk to the local Area Agency on Aging--(usually we find these people through Senior Centers. GET DOWN TO THE COUNTY COURT HOUSE AND SET UP YOUR BUSINESS NAME NOW NOW NOW!!! JUST SOLE PROPRIETOR FOR NOW...YOU CAN CHANGE THE BUSINESS STRUCTURE LATER IF YOU WANT TO.

I had to put myself in the shoes of a person that our society deems as being, "poor". I had to ask myself what kind of care would I want from a nurse if I was going to pay for it out of my own pocket. And, if I was going to pay out of my own pocket, how much would I be willing to pay? I tried to look at my services through the eyes of the patient, not through the eyes of a capitalistic, all consuming entity that calls itself an 'employer'.

People in my area had become used to agency nurses coming in for a spell and then cancelling the care because payment resources had been exhausted due to budget cuts and especially because of the changes in Medicare rules and regs. Most often these folks had not been able to grasp, in the time given them, the protocols for self management that the home care nurse had been trying to teach them....and no way could they afford continued care by paying out of pocket for private duty.

Let me give you an example of my version of "filling the gap": A diabetic patient was being seen by home care nurses for a stage IV ulcer on his ankle secondary to venous stasis compounded by peripheral neuropathy . They noticed he needed nail care and called me in to do that; the patient agreed to the $15.00 that I charged at that time. We agreed to foot care every month--he felt he could afford that. The ulcer healed to Stage II and the nurses pulled out. It was obvious that diabetic teaching and preventive measures to inhibit further break down were not well absorbed by this patient. His hygiene was poor, he did not follow through with dressing changes as prescribed, he did not maintain a healthy diet suitable for a diabetic; his choice of foot wear was abysmal and he was not interested in taking his medications on a regular basis. He checked his glucose levels when he felt like it and he left insulin needles everywhere except where they belonged. (One of his nurses complained to me later that this man did not seem to understand the words: "home bound", and that he would have been discharged from services anyway for violating that rule.) He was rough and gruff and tough.

My assessment of him was that he was a slow learner and that he was also one who could be intimidated by authority figures...so I met with him each month on his own level. When he swore, I swore; when his focus would wander away from what I was teaching him, I would get my face into his face and tell him to get his head back into the program; I made certain not to wear anything that looked like a nursing type uniform. Each month we'd have a little impromptu test. I tested him on everything from diabetes to pressure points, to hygiene, to diet, to proper shoes to medications. I showed him pictures of freshly amputated feet and legs that I found on the web. After 12 months the guy was doing not too bad on his own--even washing his own feet on a regular basis and had bought 3 good pair of K-Mart shoes which he interchaged on a regular basis. His ulcer cleared up just fine, his blood sugars were as close to normal as they will ever be and, just to make him feel really good, I taught him how to cut his own nails using the right tools. The total cost for his care for one year was: $150.00- about what it costs for one podiatry visit for nail cutting--or, about what insurers are charged by a nursing agency for one home care nursing visit. I spent a total of one hour at each of his visits leaving me plenty of time during the day to care for other folks.

Know what? I'm in business for people. I work for people. Any nurse does no matter where she/he works. It's what we are here for. It's people who pay us our salaries. Average people on the street. They are our employers...they are our contractors. It's their money that is being utilized for the reimbursement of services.

Actually, it is the hospital or clinic that is sub-contracted by the masses of average folk. When a patient is admitted, it is HIS money that pays for the insurance that pays for the services provided. The insurer gets payment from the money that people give them for the service. No matter how it's sliced or diced, people are our employers. So why not be the people's nurse? Why not sub-contract soley to them? Why not let our REAL employers tell us what they feel is fair and negotiable as far as payment for services? I have found that when people are paying out of their own pockets for nursing services they tend to be more attentive and serious about the care being given and the teaching that goes along with it.

I am not shy about telling people the cost savings to them. I tell them what the insurer is charged for a one hour nursing visit in my area; I tell them what the average local podiatrist charges Medicare for a nail cutting; I tell them these things and they ask "Well, why then won't insurance cover your charges which are so much less?" And I say, "Yes and that's a very good question for you to ask them. After all, you are the employer."

I'm sorry this is so lengthy. I have taken today off and this seems alot like having a conversation with someone under the age of 80! Feels good! Don't give up, Agnus. Promise you won't do that!

Peace and Brightest Blessings of the Season to You,

Lois Jean

JNJ · Dec 19, 2002

Lois Jean:

Marvelous story and one that stikes at the heart of so many of the old timers in nursing. Keep up that great work. I hope you make a lot of money (that's not mutually incompatible with being a good nurse despite what the managers may tell you). I'm close to tears having read your good stuff. Thanks for making my day. Independent Nurse. JNJ

funnygirl_rn · Dec 20, 2002

Lois Jean, I concur with JNJ, it was a truly wonderful story. You are such an aspiring person. Good luck with your business..I hope to start something myself someday....wheels are turning.

mattsmom81 · Dec 20, 2002

What a wonderfully positive thread!!! Thanks all!!:)

Agnus · Jan 31, 2003

THANK YOU I will follow your advice. Thanks for all the wonderful tips and insights.

Yes, I will file the business name NOW NOW NOW as you say.

I can't wait to share it with you. You will like

Ok I am getting on the phone now and requesting the forms from my county clerk.

This was just the stick of dynomite I needed. I do not know when I have received such encouragement and support. I think never. Thank you, thank you, thank you for not only your faith but your guidance. You are right I am chomping at the bit. How did you know?

I have been looking for some direction. Exactly what I want to do. This is a very good place to start.

Isn't it ironic that some feel the liability is too high to provide diabetic foot? Yet these are the folks who would benefit most.

I am going to the senior center this week and talk to the director, about my plans.

I will print out this thread so I can go over it and and not miss any of the suggestions.

Agnus · Jan 31, 2003

Ok. Step one done. Called County Clerk the forms are in the mail. $20 one time fee for filling name.

$100 year business license. Payable quarterly.

She asked if there were any regualtions controlling this type of business. Said, "I know a doctor who is doing this but I don't know about nurses."

I told her there is nothing in the nurse parctice act the prohibits this and that the nurse practice act is the law that governs my practice. She was happy with my answer.

BUT DANG, I should have asked her who the doc is. Could be a good resource.

I was too bussy concentrating on being professional and making sure I did not shoot myself in the foot. I was excited and concentrating on my immediate goal (getting all the right forms and info for filing)

Well I can ask about the doc later something to put on my to do list.

Taking the first step feels good. Pretty painless. I know I haven't really done much yet. But you know what they say about a journey of a 1,000 miles.

We often fail to take even the first step. Common someone else's turn. Who's next?

I have to go. I have things to do to get ready to go into business.

LoisJean · Feb 1, 2003

:balloons: WAY TO GO, GIRL! How does it feel to have something that belongs only to you? It's kinda like giving birth. Now....RAISE THAT BABY!!

Anything, anything at all Angus...let me know how I can be of further help. And please keep yourself anchored to our Forum here. Keep us posted regarding your progress.

Peace,

Lois Jean

Agnus · Feb 1, 2003

Hmm!? "Raise that baby," huh? Well I hadn't though about it this way. Yea it kinda is like that and I get to name it too.

I guess I'll have to pick out it's first clothes and plan for it's education and ..... Hey! I thought I went through menopause all ready. What happened?

Well Lois Jean I would be honnored if you would consent to being the godmother. It seems you have already assumed the duties.

JNJ · Feb 3, 2003

Kae et al above: You can do this. I was an independent ten years ago (and a foreigner to boot!) and was successful in my humble way.

You can do the Medicaid (Medi-Cal) paperwork. Just handle it as if it were a complex patient. Assess and set priorities for interventions and do these one at a time. Nurses are wonderful at complex tasks because we live our working lives doing just that.

As for finding clients this is where you need all those really creative nursing skills to come to your aid. You know how we all improvise when there is not the exact piece of equipment we need - just use this skill.

Agencies: Yes Kae, many children get their care thru agencies, but most kids do not get the amount of hours Medicaid allows because the agencies can't staff that much. Some kids don't get any nursing hours because there is no agency willing to take them on and the parents do not know what to do next.

My ideas for finding the clients: Contact the Regional Center (you can actually do some hours for them while finding your Medicaid client). Make an ally of the nurse at the Regional Center and she will want to help you and others fill the care needs for these kids.

Contact discharge planners at the nearest children's hospital or unit and talk with them. This may take a while, but quality networking is the way here.

Try contacting one of the web based sites where chronically sick people talk with each other and post so their friends know what is going on. I only know of caringbridge.com, but there must be others. Ask for help. Try talking with a mother of a child who gets nursing thru an agency. She may know of others.

Question every regulation you read; many can be 'accommodated' by an independent RN. The rules (in CA) say we can only do private duty Medi-Cal when an agency is unable to meet the needs. It's amazing how often this can happen when the family is 'high profile' (PIAs who can be wonderful to work with if you are 'their nurse') etc.

Try a discrete, quality advertisement in the LOCAL newpaper in the better class areas. I know one woman without any nursing qualification who has kept herself into her 60s with word-of-mouth referrals in this type of work. She just gets trained for each child as the parents did. She has a waiting list and impeccable references.

Let's keep brainstorming until all you quality nurses have empowered yourselves.

PM me if you wish for my small document on getting started with Medi-Cal in CA. (Need to find the client first).