Nurse Entrepreneurs: Setting and Achieving New Goals
by Peggy Helton, RN, EMT
After 21 years of working as a Registered Nurse, it has finally occurred to me that you absolutely must be an entrepreneur to be in the nursing profession. The nurse is always innovative and original, and the nurse is manager of the patient’s total care, individualizing it to meet the patient’s specific needs.
Perhaps it is because of my foundation of almost 15 years in critical care and emergency nursing that it was not a far-reaching concept to start a new business. After primarily serving in supervisory roles, along with nursing administration, I decided that it was time to move outside the walls of the hospital and venture into the home health arena. Upon my move I was dubbed the “IV Clinician” and most of the work requiring higher technical skills was sent my way.
It was during this time that I met my current business partner, Sandy Propst. We worked together and managed a successful private nursing service that included not only third party payor skilled nursing services, but also private duty and industrial health services. We worked together almost as an extension of the other.
The private sector of home care was still in its infantile stages, and no one really wanted to deal with it. In the midst of many mergers and acquisitions of the 1990s, I decided to try my hand at occupational health and leave the murky waters of home health. I worked as an independent contractor for an international company that had a small industry locally. I spent about two years in this role and learned many things about industrial health, case management and worker’s compensation.
Sandy and I kept in close touch and always mentioned the many opportunities for an independently owned and operated agency. Finally, we decided to be the ones to take the initiative against all of the advice of our family and friends. We contacted an attorney whose firm specialized in labor law and gathered information. We were advised to set up a corporation and discussed all of the legal ins and outs of operating a business. We met a CPA and made decisions about finances, the breakdown of tax liabilities, and informed the attorney that we were ready to go.
We were in business. Premier Support Services, Inc. had been born.
We set up our operation after careful consultation with the attorneys, state health care regulators, and anyone else we could contact. We began to provide private duty “homemaker-type” services and supplemental staffing. The staffing was a huge success. We provided services to hospitals, nursing homes, physicians’ offices and home health agencies. This business grew at a rapid pace, and we had to move from working at home to opening an office in six weeks!
Sandy was working full time and I was taking calls at night. I did all of the admissions, evaluations, talking with staff, and providing orientation and education. Sandy’s background is primarily business with 15 years of experience in home health. She had a very strong concept of how to manage the day-to-day operation of setting up and running an office. Because of her health care background, she knew the forms we needed and the guidelines to follow for our contracted clients, and she had a strong commitment to customer service. Her role was anything and everything that did not require a nursing license to perform.
With a strong background in privately owned hospitals, customer service and managed care to complement my nursing degree, it seemed to be a perfect fit. A desire to continue learning led me to expand my skills and capabilities. I completed my training and state testing to become an emergency medical technician and became certified in chemotherapy and PICC line insertion. I came on board full time in July 1999. We began receiving calls for health fairs and industrial services through many contacts I had made at the local level and through the local emergency department. We scheduled and provided health fairs and wellness screenings in cooperation with a local independent medical director. Sandy and I literally worked from 4 a.m. to about 8 p.m. or later and traveled many miles. Because of these contacts, we began staffing industries and providing their health-related education.
As the industrial health program grew, I saw a huge need for a managed approach to the worker’s compensation services that existed in Morristown, Tenn. We submitted a proposal to one of the local emergency rooms for the implementation of an industrial health clinic that was physically located within the walls of the emergency department, but managed by our Premier Support Services, Inc. With a great deal of input from the local industrial leaders, the proposal was accepted and became a huge success. The industrial leaders designed the program. The primary component of the plan was good follow up and good customer service. Fortunately, I had the expertise from both the ER side and the industrial side. This led to many other industrial opportunities. An opportunity arose for me to take a case management certification program that greatly enhanced our company’s role for the local industrial leaders.
We continued to grow at a remarkable rate. By September 1999, we began to be courted by TennCare case managers and Medicaid Waiver services to contract for private duty services for a severely underserved population, including medically fragile and mentally retarded children. Our contract negotiations and state contacts paid off, and we added another specialty. As local chamber of commerce members, we were afforded opportunities to network with other business owners.
Coming from corporate America backgrounds, it is a very daunting experience to realize that you are 100 percent accountable for all of the actions you take, for ensuring that the care provided under your direction exceeds expectations, the staff is competent, the patients and their families happy, and most of all, that you can in fact meet payroll for all of these people.
No one really understands how growth of this magnitude can be both good and bad. The good side is obvious. Your services are needed, they are utilized, and growth is inevitable. The bad side of growth is a more subtle. Suddenly, you are faced with a 200 percent growth in the volume of your business and the amount of money you are billing. In order to bill this amount, you must first provide the service. If you provide the service, you must pay the caregiver. Unfortunately, this is not where the buck stops. If this were a perfect world, the cycle would flow without problems. We found that the turn around time on some of our payors could be as much as six months in remitting payments.
We found ourselves at another turning point. We could stop here and never grow or we could look for help. But where do we go?
If I have learned anything from this experience, I realize that being assertive is no longer always enough; sometimes you must be aggressive to get what you need. It is not uncommon for a critical care nurse to perform as an assertive nurse or leader, but it is not always common or admirable to be aggressive.
Cash flow isn’t something you can always depend upon and it does not always magically increase the same day that your business and payroll increases. This was probably one of our biggest initial challenges. I searched diligently on the Internet for services that would help small businesses, disadvantaged businesses and businesses owned by women. The information I found was almost always the same, “It will take about eight to 12 weeks to process your paperwork,” and “You need to have credit established in your business and be operating for about three years.”
Time was something we didn’t have. How could we do that when we had only been in existence for nine months? How in the world were we supposed to stay in business for three years?
After extensive searching on the Internet, I found Small Business Association contacts at the University of Tennessee in Knoxville and East Tennessee State University in Johnson City. I contacted Rob Lytle at ETSU who provides business assistance for small businesses. I met with him and explained our situation to him. He was very attentive and had a real grasp of what we were doing and what we needed in a short period of time. All of his assistance was provided to us free of charge. He was professional, available, and most of all interested in listening and helping us. This Small Business Administration is a wonderful resource for small businesses.
Rob assisted us in formulating a simple process for projecting cash flow with a reasonably anticipated budgeted increase in business. He helped us see how profitable we would or could be and determined the information to take to the bank to assist in obtaining a loan based strictly on our accounts receivable. Unfortunately, in the private duty staffing arena, there are no assets to pledge, only your “service” business.
In September 1999, we hired our first director of nursing. In the coming months we hired an office manager, a clinical coordinator for private duty, and an industrial health coordinator.
In March 2000, we opened a small office in Lenoir City. We had provided some industrial services in this area and found a real need for private duty and staffing services here. Later in the summer, we added a clinical coordinator position for this office. Trying to manage the quickly growing office in that area from Morristown proved too difficult. The individual assuming that role had to be accountable for management of a “satellite” office, as well as marketing and developing the client base and staff.
We then added an education coordinator to assist us in providing a thorough orientation program, developing competency documentation to a greater level, and offering our staff continuing education. We felt this would enhance our employee satisfaction and retention in addition to providing quality care to our patients.
Sandy and I felt that we could provide greater continuity of care if we obtained Medicare certification for our agency. However, we were told by the Tennessee Health Care Facilities Commission that no new Certificates of Need were being approved, as there were already enough Medicare certified home health agencies on the books for our territory.
At the end of 2000, we discovered that a home health agency was closing its doors and would be for sale. Again, I searched the Internet and sent an email for information. Two days later I received a phone call from the corporate office of the agency in Sunrise, Florida-they wanted to talk!
Sandy and I did some investigative work and then flew to Florida at the end of January 2001. What an adventure! At first we thought we would never need six rooms or more than one cordless phone for our business. Now we were flying across the country to see about buying a Medicare certified home health agency. All of our office space was full; we had a five-line phone system, and a digital cable computer network. We had reached a real turning point.
We hired a consultant to evaluate the business and make recommendations for pursuing contractual negotiations. We decided that a definite opportunity existed for franchising local operations to local owners. This East Tennessee license covered 30 counties. After months of negotiations (another learning experience) we became the proud owners of this new entity. Now we are a full-service agency having the capability to offer Medicare certified home health care. Premier Support Services, Inc., an affiliate of Interim HealthCare, offers services we would never have been able to dream of offering alone. We were thrilled to be an independently owned and operated agency, not a small business swallowed up by a big corporation. Due to this new purchase, we had to open an office in Knox County. This was our third office and the parent office for our Medicare certified home health agency.
The Tennessee Nurses Association has been a wonderful resource for me personally and for our business. Without this organization, we would never have had the opportunity to share our many accomplishments and adventures. There is truly much to be said for belonging to a professional organization. I appreciate the opportunity to be proud of being a nurse, have my accomplishments recognized, and promote a career that I truly love. Nursing is the only thing I know how to do, and it’s the only thing I want to do. It is like no other profession. Where else can you take care of patients, learn new skills, change jobs within the same facility or organization, be a teacher, a caretaker, a technical expert, and most all an entrepreneur? Only in nursing.
March 1, 2002 marked our third year in business. Today, we have three operating offices, eight management positions, approximately 70 employees including the per diem staff, and approximately 40 employees who work 32 or more hours per week.
Sandy and I have realized a dream that not everyone is fortunate enough to reach. Because nursing nurtures the entrepreneurial spirit within, we have been successful. Our dream has been realized through the art of nursing.
Peggy Helton, RN, EMT, recently expanded her nursing staffing agency, Premier Support Services, by purchasing a franchise of Interim Healthcare, a combined provider of home care and supplemental staffing. This franchise will provide home health services to a 30-county territory covering the majority of East Tennessee.
|
