Researching Switching Gears to HHC - Entrepreneural Route

  1. To all my colleagues:

    I have been lurking on the HH Forum lately. I am researching the possibilities in providing HH as a subcontract (vendor) to an exisiting HHC Agency. I am also researching the possibilities in providing HH services to individuals on a private pay basis and maybe even Meidcaid reimbursement (ugh... the paperwork has me intimidated already).

    I am a firm believer in, "not one of us can think as well as ALL of us". hmmm I think I said that below too.... hmmmm oh well

    To all my favorite colleagues and then some, "what say YOU". What ideas can you help me with in brain storming?

    I have been discussing this via PM with another colleague who has a very succesful business already. She, who shall remain nameless (until she decides to step up to the plate and take the mike), is a wonderful caring Nurse who has braved the Entrepreneural Nurse route and is a SUCCESS.

    It is via this forum that we have decided to "take the conversation" for all to view and learn from.

    I have decided, "To Follow My Dreams".

    Come and walk with us. Learn, listen, and PLEASE add your 2 cents worth!

    Last edit by nightingale on Nov 22, '02
  2. Visit nightingale profile page

    About nightingale

    Joined: Apr '01; Posts: 6,312; Likes: 106
    RN, CLNC, Entrepreneur


  3. by   NancyRN
    Nightngale, this sounds so nice! I'm afraid of the paperwork too. I can't wait to see what others have to say. I'm ready to try doing home visits for those who just want to pay on a per visit basis.
  4. by   LoisJean

    I listened with great interest the report on the CBS Nightly News tonight of the small, but growing number of physicians who are no longer doing insurance billing for the patients they see in their offices-- (The doctors professional fees). These doctors have found that by chargeing a flat fee to each patient who comes in they save $1000s in overhead. A Mississippi doc charges a flat fee of $40.00 per patient per office call. Of course all tests, etc are covered by insurance. The point is that by eliminating this part of the paper work, the business saves time and $$ in the long run and the physician actually comes out ahead profit wise, because he is not waiting for a watered down check from Medicare/caid or other health care providers--the deal is cash payment at time of service. I am willing to bet that these are the docs who operate small clinics with minimal staff... just like a self-employed person who has little, if any, resources to keep them viable over the long haul.

    I do not believe that the self-employed nurse acting as a sub-contractor for an Agency, institution or physician is the one to be doing the insurance billing if her work is billable. It is the responsiblity of the Primary Agent(cy) who is requesting the services of the contractor. These are the people who pay other people to do the billing. Believe me, if I had to do the billing for my Medicaid clients, it would be reflected as an additional charge to my fee for services--a whopping big charge, it would be, too!

    The problem for the entrepreneural nurse is start up costs and making some kind of living wage while getting her business onto it's feet. It is uncommon for anyone to be able to start their own grass roots business without having to work a 'real' job at the same time. So, in most cases, we use our 'spare' time to build up our businesses while working for someone else.

    I knew that the work I wanted to do would not be covered by any health insurance provider because it is not considered a 'skilled' care when provided by a nurse--it is considered skilled when performed by a podiatrist. Well,--I knew that the demand for the type of nursing service I could provide was high-and that people would be willing to pay out of their pockets for it IF it was a fair and reasonable charge. By calculating the initial outlay for the supplies I would need and factoring in the size of the territory I was willing to cover, I saw that I could more than likely make more money on my own than I was making working for an Agency. #1: I could control my territory-decreasing mileage and car maintenence expenses; #2: I could control supply costs; #3: I could put 10% of my earnings into a savngs account, letting it earn interest and put the rest into my household to help with bills, food, etc; #4: I knew that everything, everything, everything which reflected back onto the business was deductable--even the laundry soap I used to wash my work clothes. I also knew that I would show a loss at tax time- that loss coupled with my deductions would give me money back from Uncle Sam.

    I also knew that the people who used my services were telling other people about my services and so those people wanted my services and people they knew wanted my services and so on, and so on, and so on. Word of mouth saved me a bundle in advertising. There is much more I can tell you about how my business grew, but will save it for another post perhaps.

    I think that people will pay for convenience--especially if it is unique and offered in the home setting. I think that if a nurse has a PARTICULAR skill that she can provide ALONG with other cares-or whatever it is she feels she wants her business to be primarily-she will have a foot in the door of successful self-employment.

    What I want to read in these posts is what are you are thinking about as far as self-employment? What is it you want to do as a self employed person? Describe the venture. Even if it's only an idea at this stage.

    It takes a particular type of person to wing it takes an independent spirit, a trust in ones own skills and a deep desire to be free of the one thousand entanglements that prevent a nurse from providing the care she truly wants to give people--to be able to practice her science and art as a free be as unencumbered from bureauacratic clutter as possible.

    I cannot believe that out of all the nurses posting on this BB, that only a handful have considered self-employment as a professional career option. But, we shall see as time goes by--it is vital that I hear from all of you...because, for a long time I have felt that certainly I AM the only independent out here...and frankly, it's been damn lonely. So there, I've said something! D

    Lois Jean:
  5. by   nightingale
    Dang Lois Jean... you spoke of being valued in our work. How little I feel of that now as an Agency Nurse. Yes, there is a bit of it here and there but...

    When I did wound care before in the home setting I loved that. I was in a high learning curve. I was not fully trained and did have to consult the WC Specialist regularly. I know there are Wound Care Certifications etc.

    I have the ability to subcontract to the Agency I spoke of to "Start". That is a blessing. So far price has not been negotiated so that is a big "if".

    I may actually get a travel contract to supplement my income for 13 weeks etc. That would totally free me up on, oh, 4 days a week.

    It is great that you researched the market first before venturing out. Foot Care is such a big need of the elderly. Additionally, Diabetic Foot Care is vital in avoiding foot ulcers and subsequent amputations. I see that as a need in any community. Quite frankly, I do not know if I will be good at that or have a talent in that specialty.

    Another colleague I spoke to about this suggested they might volounteer at a senior center to provide these services free of charge. Coincidently, my senior work at a University did just that but would not generally treat diabetics (what a loss for the community). The instructor sited liability etc.

    Quite frankly, I love to treat the elderly. I find them so much fun to listen to. Providing information of teaching meds, patho. of disease processes, was always so valued by them. Maybe I was lucky and had an unusually astute population. All of my clients were willing to help themselves too.

    So for doing what I like? hmmm.... I will have to challenge myself on that one.

    There are unmet needs of the community that I would like to fill. From a business perspective, that is my approach. It has been such a long time since I was able to go around the table and ask myself, "What services do I like to perform"?

    I KNOW there are more then the two of us. Let's here from YOU!


    PS.. I posted tha article mentioned by Lois Jean on another thread here at the Entrepreneural Forum titiled, "Doctor and Nurse At Your Door".
    Last edit by nightingale on Nov 23, '02
  6. by   nightingale
  7. by   sunnygirl272
    i have often not-entirely joked that we should make a mobile unit for dressing changes, private pay, for the clients that do not have family/friends that are reliable enough to be counted on to do dressings...and yet the clients fall through the cracks..are not eligible for home care for various reasons....
  8. by   nightingale

    I agree there is probably a need for the service. What I would love to see are more services available directly by nurses who can access those clients dirctly.

    It slays me that WE do the work, meidcare bills, and the "middle man is the BIG profitable margin.

    I actually had a manager (who I subcontract with through my business at a facility) tell me, I can't allow you to make more then what I make! Uh... but why?

    I have worked 10 years towards my colleage education.
    I am still paying on my school loans.
    I put MY license on the line every day to meet patient needs.
    Without ME, that particular patient care billable service, would not exist.
    I am the one who goes home exhausted, needing to disinfect, stay abreast of new infornation/education to provide the highest quality healthcare for my patients.

    I love my profession. BUT WHY should I not be compensated appropriately.. instead of the manager?

    I am capable of managing myself... thank you.. may I cut out the middle man sometime soon? I hope so... cause I am tired of not really being successful and profitable....
  9. by   LoisJean
    Sunnygirl and Bonnie;

    Precisely so. Sunnygirl, your thought regarding a mobile unit for providing in-home site dressing changes is an excellent one. I cannot tell you how often I go into a home to provide foot care and ended up doing a dressing change, too, because there was no one else to do it. In most cases these are elderly folks who either live alone or there elderly mate is unable to perform the procedure. I have had elderly people admitted to nursing homes because they have exhausted HHC services--most of these folks don't need a nursing home--they need home care nursing services. They simply could not respond to a HHC nurse's ministrations in the time alloted to them...

    There has got to be a way to get well motiviated, self employed nurses into a home care setting and be reimbursed by health care insurers for care delivered. It seems to me that docs would be falling all over themselves to get such care to their patients--willing to sponsor or contract independent nurses to provide care in such a manner for their patients who need assistance beyond what HHC agencies can provide. And it seems to me that these docs would be more than willing to run the billing through their own offices.

    And, Bonnie is right. In order for a business to be successful there can only be one manager--and that is the person who owns the business. Self employment is attractive to many people precisely because of the autonomy it offers. When a business owner provides a service that is attractive to a consumer, it is not the place of anyone else to decide what the fee for service should be based on...the consumer is the one who decides what is fair or else he won't participate in the service being offered.

    Now I know that when I worked in HHC, the insurer was charged $110.00 for each of my visits; I was paid $18.00 for each visit. There is something really wrong with that number, in my opinion.

    I knew that I could work independently, make a living, pay my bills and maintain my business on far less than $110.00 per client. I knew that I could provide a better service and that my service could not ever be discontinued unless the client expressed that desire directly to me. I knew that I could control my out-go as well as my in-come. And I also knew that I would make a profit- that my hard work was not going to pad the pocket of strangers who had no concept of what my knowledge and expertise entailed; people who cared less about the work I do, but cared more that my work bought them a profit margin.

    There are so many facets to home care nursing that I truly believe that those of us who want the independence of self-employment, have the knowledge and expertise to provide skilled cares, can find a myriad of services to offer to people who no longer qualify for nursing care in the home. And because we can provide that care FOR LESS than what an agency or other clinical setting would charge, it seems to me that we would be looked upon with great interest by insurers like Medicare who are loath to fully reimburse for increased charges--thus creating cuts in insurable cares--it's in the area of these cuts where we would fill the gap.

    The question to all nurses who have a pull/tug/desire to go independent is- what gap would you fill? Where do you see a need that is no longer being provided for?

    Lois Jean
  10. by   kae rn
    Would so love to be totally independent as a nurse. My area that I enjoy is caring for med frag children private duty. Have applied and received my independent provider number in my state and can bill directly without an agency getting the profit. Problem is: the politics. Jobs are hard to find because most parents are utilizing the agencies. I think as a parent, I would rather pick each individual person who comes into my home and manage them myself. But, I think parents are overwhelmed and take the easier path, or perhaps don't even know about their options. Plan to keep plugging away, working a variety of jobs and building my client list. Probably a few years or so done the road, but doable. Nothing ever happens overnight.
  11. by   nightingale
    Kae: Are there an waiver programs that would suit your patient needs?

    I can not imagine how to market your services; but I am sure there is a way. Maybe others will have feedback?

    I am completing a samll business class that is sanctioned by the local Chamber of Commerce on Entrepreneurship. Perhaps you might be interested in what is going on in your area for puting together a business plan and it willl include marketing.

    I wish you well in whatever you decide. Please let us know how you are doing,

  12. by   Agnus
    My concern in launching a business is I live in a very economically depressed area. Were I still living in Sacramento this would not be a problem. Charging a fee without using medicare/medicaid might not be a profitable enterprise in this area.
    I know many people here would rather go without necesities than to pay for them even when they have the means. It is a terrible poverty mindset.
    There is also little motivation to take responsibility for ones own health here. Education is low. Our dropp out rate is one of the worst in the nation and is the worst in the state. Only 2% who actually get to the point of entering community college (locally) graduate.
    I want to provide direct sservice and particularly direct teaching but there has to be a market. This is scary.
  13. by   nightingale
    So Agnus.. don't quite your day job and proceed slowly. Lois Jean found her nitch. I know there are many markets

    If it is too scary then don't do it; if it is rewarding then try it.
  14. by   LoisJean
    :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 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 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

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