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All right, good afternoon, everyone. I'd like to welcome you to our HCC Intelligence webinar today. We've got about a minute or so until we start. I do just want to remind all of our attendees as you're coming in that we will hold questions until the end of the presentation. Please make sure that you have your audio plugged in. I would recommend Google or Firefox. Those will be your best option. So if at any point during the presentation or prior to you find that you're having a hard time, please exit out if it's Internet Explorer and come back in through an alternate browser. You will be receiving an email after the formal presentation today with a short survey. And we'll remind you again as we go through this, just making sure that everybody gets out of this what they're hoping to get out of this and, of course, always welcoming feedback. So we've got about a minute until we start. And once we get going, we'll turn it over. But in the interim, we'll give a few seconds for everyone to come in and get settled. Okay, we are just at four o'clock. So hello everyone and welcome to the monthly HCC Intelligence webinar and virtual office hours. Today's webinar will be presented by the National Nurse Practitioner Entrepreneur Network and it's entitled Entrepreneurship, I Want to Start a House Call Program. My name is Danielle Feinberg, HCCI's Coordinator, Education and Research. I will be your moderator for this event. The first portion of our webinar will be dedicated to a formal presentation. We're going to cover a few housekeeping items first. While participants are welcome to submit questions, please know that we will address these at the end of the formal presentation and during the open virtual office hours following the webinar. If you'd like to submit a question, please do so by clicking on the questions box located on your screen. A copy of our presentation is available in the handouts box and can be saved by clicking on the name of the presentation and downloading it. Additionally, you will find a save the date for our NPEN-HCCI joint conference in Phoenix, Arizona in February of 2020. All participants will receive a copy of the slide deck, questions and responses, as well as a recording of the presentation. At the conclusion of our virtual office hours, which immediately follows our formal presentation, we will send out a brief survey link via email. We appreciate your feedback, which gives us an opportunity to understand your needs and decide on meaningful future webinar topics. Today we are joined by Dr. Lynn Rapsilver and Ms. Sandra Berkowitz. Dr. Rapsilver is the owner of NP Business Consultants, providing dissemination of information regarding reimbursement for nurse practitioner and other healthcare provider services. She's recognized as an expert on coding and documentation for APRNs. She's an author and educator of NP students and seasoned NPs. Dr. Rapsilver also serves as the chair of the Connecticut Coalition of Advanced Practice Nurses. Under her leadership, full practice authority for APRNs in the state of Connecticut was attained with the passage of PA 14-12. She is the Connecticut State Representative for the American Association of Nurse Practitioners. She currently works as a GI nurse practitioner for Connecticut GI in Torrington, Connecticut. Ms. Berkowitz most recently was the practice leader of global insurance broker Willis's Robust National Managed Care Specialty Practice, retiring in June of 2014. For the 23 years previous to her joining Willis, she was with Johnson & Higgins and then Marsh, acting as an insurance and risk advisor. As a nurse and an attorney, Ms. Berkowitz built a multimillion-dollar managed care practice from her strategic vision of how reimbursement of health care services would evolve and the risks inherent in those business models. Without further ado, I'd like to turn it over to Dr. Lynn Rapsilver. Thank you very much for that wonderful introduction, and Sandy and I would like to thank HCCI for having us today to share our expertise with you, and we hope that you find this information very helpful. First, we wanted to let you know that we do have some slides. Any slides that look like this are used with permission from the Connecticut State Small Business Development Corporation, and they have been graciously allowing us to use these slides today, so we really appreciate that. And they also offer a lot of tools that can help you to support you on your path, and we'll talk a little bit more at the end about how you can access that information. So our objectives for today are to describe the type of individual it takes to own a practice. Many of us were not educated in the nuances of owning a business, so today you'll find some helpful hints, hopefully, along the way. We will discuss the rewards and challenges faced in starting up a new practice and operating your own business. Do you have the chops to go forward? Are you looking at ways to start up a business and not sure how to do that? We'll help you a little bit with some of that today. We're going to identify key elements in achieving success and sustainability, because obviously if we open up a practice, we want to make sure that we can keep the doors open and keep patients coming to see us. And then we'll define some of the pitfalls and how to avoid them. So our overview today, we're going to talk about entrepreneurship rewards. We'll also talk about readiness, value proposition, what does your roadmap look like? We'll talk about validation and how do you make that decision and how do you get that action plan started? And we'll also talk about if you're ready to own your own practice, what are some of the things that you should be aware of? And we'll talk about Prochaska's stages of behavior change. We'll focus on some free startup resources that we have available for you. And then lastly, we'll finish up with a Q&A question and answer session. So first up are the entrepreneurship rewards. One of the things that's great about being your own boss is that you have the flexibility to do the schedule the way you want. You have the flexibility to create your own destiny and you can develop what you want, how you want to do it. You can develop your core values of your practice and you can develop an innovative practice model. We know that the opportunities are out there for brick and mortar, but we're nurse practitioners and we're very much innovators. And we think outside the box. And a good example of that is the Winnebago Health Wagon. They've taken their show on the road providing care to rural folks in Appalachia. And we also have met nurse practitioners who wanted to go to daycare centers or wanting to go to sites where the patients are located. So this is a great opportunity to develop some of those models and a home-based primary care practice is one of those. And lastly, we want to make sure that we have a community impact. We want to make sure that we are filling a void in our communities, that we're helping patients. And with a home-based primary care practice, we really are accomplishing that. We're bringing care to the patient, which is the best way to start. I'm going to turn over the next set of slides to Sandy, who mastered the unmute button. So I think I'm ready to go. Looking forward to evaluating your readiness. Am I doing that or is... No, I'm supposed to do that. Okay. Teamwork. Oh, my computer froze. Oh, there we go. Forgot that. Moving to the next slide. Evaluating your readiness, you got it. That's not what I'm seeing. Am I evaluating your readiness? Why am I not? Okay. Is that what you're seeing? No. I want to make sure the audience is seeing, evaluating your readiness. HCCI, are you seeing, evaluating your readiness? I am not. I'm still seeing the readiness overview. Do you want to pass... Hang on. Now I think I got it. Ah, there we are. This is one of our Connecticut Small Business Development slides. Evaluating your readiness. Am I ready is probably the question that we hear more than any other question. And I want to start out by saying it's not all about you. It's also about the support system that surrounds you, as well as the idea you have that sort of ignites your imagination. In general, it requires you to think about the family experience you have and whether they're supportive of your brilliant idea and what kinds of skill sets you have and do not have. So those are some general things to talk about readiness. The business idea, which we're going to talk about a bit more, is your value proposition. It's what you bring to the party that distinguishes you from the competition. And that's an interesting question. When home-based primary care is probably viewed as a more... Formulaic is not the right word, but actually there's a vision that one has when you think about marketing yourself to a Medicare Advantage plan, for example. It's not a brilliant concept. It's just an underdeveloped, unexecuted concept, this idea of home-based medical care, primary care. But there is research to be done, and we'll talk a little bit about that when we get to market readiness. The personal considerations. I think the financial goals that you have are really important to think about and often are not talked about because practitioners, and I would guess not just nurse practitioners, but most entrepreneurs that come from a social service mentality, do not think about the money. They think about the value that they're bringing to society. But the last bullet you see is that if you need financing, have you saved the necessary 10% to 20% to put down, and have you established creditworthiness? The fact is that you're not going to be able to get a small business credit card in the beginning. How are you going to sustain yourself for the first at least six months? Okay, next. Personal readiness. I'm not going to say that I support this, but you might find the Psychology Today online survey, which tells you if you have the personality to be an entrepreneur, sort of enlightening. I admit I spent the $12 and did it so that I know that it's not a sham. But the measures that they think about are go-getter, conscientious, self-confident, and people orientation. I don't think all those are important, but if I were to say that what I think is the most important characteristic, it's someone that appreciates that being an entrepreneur is not a spectator sport. It is total immersion in a vision. And it's not just having the vision. It is being a self-starter to make that vision happen. If you like to watch rather than do, this is not for you. Okay, next. The road that you travel starts with an idea. And that idea is your value proposition. It boils down to what's the problem you see that you think you can solve. Again, this is maybe a shared vision so far for home-based primary care. And I think the idea that people will pay for it is emerging, although it is not consistent among payers, so it's still something to think about. Unlike setting up a primary care practice that is brick-and-mortar, pretty well-tested and people accessing you, the home-based primary care does not have that track record yet. So when you think about will people pay for it, don't assume that payment is coming. You have to love what you're doing because it takes a while to get this started and it takes even longer to be contagious in your passion for what you're doing. And the last bullet is I want you to think about why, if there are, let's say, in this audience of 50 or 100 people, all of whom are thinking about opening home-based primary care practices, what distinguishes you from the person sitting next to you? And that is not so much your attributes. I'm good looking and that one isn't. That's not what I'm talking about. What I'm talking about is what are the benefits that flow from choosing you? Is it because you are available 24-7? Is it because you have teamed up with a physician who can support the home healthcare ordering that you need without any glitches? Is it that you serve a very focused catchment area that you know very well? It's what you're delivering, not who you are. I used to work for the largest broker in the world and they would start every sales pitch with, we're number one, that's why you need to be with us. And that really did not sell as well as you would think it would. So think about what your benefits are. Next. Okay. The starting point is an idea. It's the beginning of your roadmap creation. The idea of a vision, which we've talked about a little bit now, sort of suggests that you need a strategy. How do you implement the vision? And who are you going to implement it with? In a startup, the question of who your management team is and what role each of them are going to play is key when you're talking to a funder, to a bank, to a family of investors. You need to know who is going to implement and what the vision is for your strategy. But the second piece is sort of road testing your vision in a very lean way. What is the minimum you can do to determine whether you have a viable product? Maybe it is establishing geographically how many home-based primary care visits you can achieve in a day in the catchment area that you're serving. Maybe it is talking to people and developing an elevator speech so that you know that people understand what you're doing. I don't know that this is true for all home-based primary care practitioners, but nurse practitioners have a real challenge in convincing people that what they do is something that they can do independently. And that is a comparable service to a more traditional physician-based service or brick-and-mortar service. And finally, if you get past all those validation points, it's can you scale up? And you'd think that this would be a happy problem, but the fact is that when you get to the point where you absolutely can't grow unless you hire somebody and you don't have the revenue, you don't know where that revenue is going to come from to build the capacity, it's a time that businesses fold. So there needs to be some financial projection that goes into this at every step. But notice that there is no word here that says business plan. I know that people think and hear that the first thing you need to do is write a business plan. And we were very gratified when Small Business Development Corporation said, you get stuck in an author mental block if you sit down and do the business plan first. You haven't done enough exploration. The business plan will come later. The doing comes first, but with a financial projection. Okay. Validation. This talks about two kinds of validation. One is the market feasibility. Does my market support my brilliant idea? And second, are my estimates of both startup expenses and ongoing expenses, which are two different budgets, reasonable? Are they going to cover what I need to set up and then ultimately to scale up? Next. Market feasibility. I'm guessing that the who is my ideal customer is not a hard one if you're thinking about who the patient is. But I'm wondering if you've thought about whether that is the customer or whether you see the payer as a customer or whether you see the discharge planner and healthcare system as the customer. In working with practitioners in home-based primary care, the answer that I've gotten most frequently is my strength comes from knowing the healthcare delivery system and where decisions are made about discharge and transitions. And that's where I get my referrals from. So it is who you know in this business. All healthcare people have already figured out. But in talking to Brianna as we prepare for this, she said that 11%, now 15% of patients needing home-based primary care are getting it. That just blows my mind. That means that 85% of your market is untapped. And that's a pretty exciting thought when you know that payers see that there are cost savings in this. And you just need to figure out how to get over the hurdle of having them pay you to deliver those cost savings. And P.S., you've got to think about whether there is a performance bonus that you can also negotiate with the payers when you get there. Next slide. We're up to validation. There are some sort of very familiar tools in the toolkit of strategists in business planning. The one that I have seen the most is a SWOT analysis, which is strength, weakness, opportunity, and threat. And it's a quadrant. And basically, you are looking internally first to what your strengths are. And what your opportunities are, which I guess is to say things that need to be improved. And then you're looking outside your practice and asking, what are the things in the external environment that could shut us down? What are the opportunities in the external environment that could float our boat? We have done this analysis with nurse practitioner practices, and we'll show you that in a minute. But let me share with you one anecdote that I heard recently that I think fits very well into external threat. When continuing care communities were first planned, there was a view that people would ultimately migrate into that kind of a living situation. And then virtual practice came into being, and home-based primary care came into being. The census started to fall in continuing care communities because they had not taken into account the telehealth and home-based care visits. They had built the medical component costs into the projections. And now they have to think about how to back them out. I guess that means that one person's threat is another person's opportunity. Next slide. This is the nurse practitioner slide You can look at it as you wish. It was just it's sort of a template for you to Get your brain cells working on filling out your own SWOT and this Often investors are looking for a SWOT analysis when you come looking for money They want to know how much you've thought about this idea Can I chime in just for a minute just to say What we want to try to do is leverage our strengths and opportunities To try to overcome our weaknesses and threats and this type of SWOT analysis when you're thinking of adding Services to your business or changing it is something that you should consider each time you do something Thanks Lynn So now we're switching gears to talk about financial feasibility and Obviously, we need to make sure that we are able to fund our businesses and we've heard many stories about Nurse practitioners who have used their 401ks. They've Took a second mortgage. They've asked mom and dad or a relative for financial support and While that may be well and good if you get along with your family, that's one thing but the other thing is that You really want to try to make sure that you are able to capitalize on some of the opportunities that are out there and the small business Startup opportunities for getting a loan are out there you can also look at grant funding as a possibility in the private sector depending on what your Actual goals are going to be and one of The things we unfortunately do is that we underestimate our true cost so we have to make sure that we understand What is our startup budget and what is our operating budget? And we need to start thinking about some of the resources that we're going to have to consider when we're looking at Setting up a practice and how we're going to move forward to make sure that we capture all the costs associated with starting up that business So we have to make sure that we get credentialed whether we do that ourselves or we farm that out it's going to be a cost We're going to need to look at potential revenue cycle manager. Maybe somebody to help with our billing process We're going to need electronic health record and those can be very very costly There's some free programs out there, but we've heard that you know free isn't always the best So I know that works well in a budget, but you have to take that into consideration as well And how are you going to schedule your time? Do you need some sort of? appointment Programming and how's who's going to cover you when you're not? Taking care of your patients or you need to go on vacation. Who's going to handle that coverage time and Then we have to make sure that we're able to submit our claims to get process so we have to make sure that we have that exchange set up so that we're able to get our Claims send in and that they're processed and then we get the payment back in an expeditious fashion And we really need to make sure that we focus a lot on you know What's involved in financially starting up that business and making sure that? We actually overestimate our costs. So if we come in under budget, we'll be much happier in the financial bottom line I Just wanted to give you one painful example from my startup history This end pen was really born out of failure and You may hear that often in startups, you know fail fast. I Have failed fast twice at this point I think I figured out a formula for success that involves getting the right partners but when I was trying very hard to get my proformas, which are the financial projections that you need to create based on Rep revenue assumptions and expense assumptions. I did all that, you know very Diligently and I came up with final numbers and The final numbers told me you'll see that red number 225,000 some odd change Is my net loss in year one and it wouldn't be until year five That there really was any significant Net income and we were proposing to funders that they split the Income And expense 50-50 with the Owners the startup. So you'll see in the green line at the bottom. Is there a funder who will invest half of? $225,000 $112,000 in year one for return of one half of $707,000 for 354 in year five. So basically a hundred and a quarter You know In someone else's control for five years. Is that the kind of investment? That a funder is going to make and the answer is no and and what I learned from this among other things was that we can't Expect that our fee-for-service reimbursement as it now stands is ever going to make enough margin For investors to really take interest in unless we get find ways to supplement that revenue with pay for performance There's such things the bottom line. This is the the slide that sort of stopped me in my tracks in starting up an NP led worksite clinic startup Next So now you have this great idea and you want to implement it and you decide that you want to take on business ownership You've done your education and due diligence. You performed your SWOT. So, you know what your strengths are you know what your weaknesses are and you know what your opportunities are and you've identified ways to maximize those strengths and reduce your weaknesses and Got your resources, so you've located a site you've gotten your EHR you've recycled management You've gotten credentialed. So the question comes in is are you ready to pull that trigger and go forward? So some of the decisions that we have to think about is, you know Let's make our decision on facts and not what we feel or think nurses are very Sympathetic and we have to think that when we're going forward with business we really need to base it on facts and we need really need to make sure that we've done our due diligence and our Homework and making sure that we've made those decisions that are going to make us be successful We also need to know if we're gonna make a difference in the marketplace So we want to make sure that you know, who is our reach? Who do we want to go to who do we want to reach and it can be? The payers to make sure that they'll pay us it can be our customers our patients What do we say to get that market generated? Do we have to go to the payers and Say look I want to create this home-based primary care practice and I think that I can be a value because we can reduce readmission rates and we can provide the care at the home and those are all cost-effective ways to deliver care and What do you want? What do you want to have happen? Do you want the payers to be able to pay you? Do you want the patients to be able to find you? Those are all things that you have to think about and are you gonna generate enough sales to achieve your goal? how many patients are you going to need to generate enough revenue to keep your business going and Many folks we've heard throughout our travels are trying to Keep their day job as they're trying to create their startup business. And at some point there's going to be a crossroads where you reach and you have to say hmm, you know, do I continue on the way I am or When can I make that decision point to abandon my day job and take on this business entrepreneurship? so we have to make sure that we understand when that point is to be able to make that transition and Did we justify our investment in risk, you know, what is our risk if we fail? most of the folks that we talked to Even if they've made some poor decisions along the way are still figuring out a way to make it work. So it takes a lot to Get us out of that mode but for the most part we're trying to find ways to make sure that we keep our investment going and And again, are we filling a niche and certainly home-based primary care does fill that our patients depend on it our providers depend on it and We depend on it So why would somebody want to choose you to make this decision? To go forward with a home-based primary care business. That's the question that you have to answer. What makes you different? What makes you better? What makes you? have that Special sauce to go forward So the Small Business Development Corporation does provide us with a startup checklist so once you've made that decision to move forward you really need to start that process of creating that business and The first thing is to select a business name and this sometimes can be very difficult But what I would suggest that you do is you do some research on this make sure that you google to make sure there's no other person with that same business name, especially if it's something fairly common and you also want to make sure that you don't Name your business as your name Wendy Wright who is a nurse entrepreneur who has her own business has her businesses as Wendy, right? And she said unfortunately, she didn't think about the possibility that she might have to sell her business at some point to retire. So Probably naming it your name is not such a good idea But you do need to make sure that you have to do the search to make sure that it doesn't already exist someplace else and then you're going to apply for an EIN employer identification number and Then depending on the state that you work. You might need to have a separate state tax registration number and Then if you're going to have a brick-and-mortar you need to know whether there's any specific licenses or permits that you're going to have to take out in order to make that happen and Then you might also need to register with the Department of Labor, especially if you're going to be considering having employees so be aware of that and Then if there's anything that you need to trademark, you'll want to make sure that you do that as well And how are you gonna brand your business? How are you gonna market it? Google Business is a great place to start because it provides you with some business startup It gets you're out there in the the search engines So that's often a very good place to start and you would definitely want to develop a website so you want to make sure that you have somebody reliable to start that website and make sure that you keep it going and Then you may need some sort of insurance whether it's business insurance dealing with liabilities slip and fall So these are some of the things that you have to think about as some other opportunities to Get those checklists going and get things started So the next step is am I ready to start my own practice? You know what you need to know before you open the doors and many entrepreneurs that we've talked about have experienced regrets along the way That they might have done a few things differently. So with that glass of wine in hand, let's learn from some of these Opportunities about things that we should know could get us in trouble and things that we should be focusing on You want me to do some of these Sure, why don't we do every other one? How's that? Okay penny wise and pound bullish first of all these slides and these wine glass in hand thoughts come from David uncle who is a nurse practitioner who has started several startups and presented for us in 2017 and He said this slide basically says over the long view pay somebody to do it Which goes absolutely against the grain of every startup entrepreneur we've ever run into who is trying to you know get her sister to do collections and her mother to do appointment bookings and You know David's view is credentialing Allow six months, you know, it's one of those things that You misjudge how soon revenue is going to start simply because you don't understand How long it takes to get credentialed or how to speed up the process to the extent that's even possible hire someone to do credentialing because who knew that CMS applications had blue ink not black ink and Who knew that Payment denials we're gonna make up 25% of my revenues that I'm losing every month The person that would know that is the revenue cycle management firm that you hired from the get-go who by the way will charge a percentage of Revenues collected but until you're collecting revenues, they are not collecting revenues. So it's worth Investing in some others who know this business better than you do so that you can focus on what you do best We know that this is a Setting that is not for everyone but when you're desperate to hire staff because your business is growing and you don't think about how to protect yourself from bad hires like probation periods like Having credentialing expenses paid for by The new hire with the commitment that You will reimburse them for those credentialing expenses once they get through the probation period and Again hiring family and friends a recipe for disaster. That is the most common theme that we hear Next is capital insurance and other boring money things Again, how you're gonna fund your business is really important and trying to secure a small business loan is probably your best opportunity To be able to fund your business. But again, we've heard stories from folks who have maxed out their 401ks Second mortgage their homes borrowed from family. So just be aware of the opportunities for that financial commitment Do you need to supply some equipment and how are you going to do that? And can you partner with somebody else to make this happen? Definitely need an accountant you want to make sure that you find someone that will help you to understand what your profit and losses and Help you to understand those basic accounting principles that will help keep your business going forward And again billing and revenue cycle management again This is an area that we don't pay a lot of attention to until we're in trouble often And it's very important that we make sure that we know what our bottom line is that we know that the cash flow is happening That we know once our claims are submitted that somebody's checking to make sure that we've actually gotten paid for them And then we get paid correctly. Some of the insurers are actually down coding visits. So it's important. You understand to check each Claim that comes back to make sure that it is accurate And again a line of credit you have to make sure that you understand the financial impact that you're going to need some extra Cushion for the first six months because again the credentialing takes time Sending in the insurance claims and then getting that turnaround does take time as well Forever caveat Forever caveat Evaluating the practice. It's more than profit or loss It's whether You are fulfilling your vision and you're doing It within the terms of engagement that you and your family have agreed to Hire someone to do this Particularly around evaluating the practice, but I think more generally Yes, you need to be frugal Yes, you need to be frugal but don't be penny wise pound foolish I think observing trends in industry One being primary cares, you know, there are Pay for performance opportunities emerging Asking yourself. How do I take advantage of that as a freestanding practice? I think that's a really important trend that All of us are struggling with and how to create critical mass to leverage payers to recognize us for performance We've already said expect to lose in year one Maybe I didn't say that but expect to lose money in year one and maybe in year two I know that n-pen in year one Lost something like thirteen thousand dollars because we decided That we were going to pay for you know an underwrite our first educational conference And we knew that that was going to tank us But we also knew that we would not be able to establish our identity as a convener as a thought leader Unless we did it so we did it Um, and we're still here to talk about it Expect heartache And heartbreak And Then again, the bottom line is for all the things that we've told you Every single np entrepreneur has said they would definitely do it over again definitely, so You know, it's not for the faint of heart. But for those that have accepted this challenge, it certainly has been very rewarding And the last section that I wanted to focus on was perchaska's stages of behavior change And these are the five stages of behavior change and there's actually six But it was a fear Transtheoretical model that was devised by perchaska into clementi in 1983 and basically it was to It was implemented in changing behavior with people trying to quit smoking And what they found is that you can actually conceptualize a process of an intent behavior to change And there's five stages that people would go through when they go through this change There's pre-contemplation Contemplation preparation action and maintenance And there's actually a sixth one that they've identified called relapse slippage or revalue and these actually can be portrayed in the model of care that a nurse practitioner Can do and so let's look at these a little bit just to go over them So pre-contemplation is are you ready to start that business? Do you see that need? Are you being pressured by others to say? Hey, by the way, you got a great idea. Let's get this rolling Or is it something that you can do or you want to do? And then the contemplation phase is that you're aware of the problem of the desired change behavior that you recognize that there is this problem and you are contemplating Creating that change, but you're not yet committed to making that you have this idea But you're not quite sure how to act upon it And this could be the longest phase because you might be sitting on the fence. They're saying well, should I do it? Shouldn't I do it? What are the pros and cons and some people get stuck in this chronic? Contemplation phase where they spend a lot of time thinking and not much time doing Because they're really struggling over this problem and they may be stalled because they they see some And they're trying to think of how to implement it and that they can't and the one good thing about Npen is that we provide that hand holding for this contemplation phase for people who are actually thinking about starting their business And then the preparation phase is really when you start to make things into action when you assess and prepare That you really want to make this change and I just you know want to figure out how to do this and you make that Commitment you're supporting your self-efficacy. You're generating your plan. You're setting your actions and you're developing things moving forward And then you have your action plan. So this is when you get your business up and it's operational And then maintenance is really where you look at Reassessing where am I at self-checking to see what's working? What isn't? What? Things have been successes what things have been failures what things that we can change? And again The stages of change do mirror the entrepreneurial process you're deciding to become that entrepreneur You're ready to do this in the contemplation phase. You're turning your idea into a reality by developing and planning for your business You develop that ownership and management of that business And you harvest the growth of that business whether it's keeping it small or exploding it and taking it to the next level And this is a process that's ongoing And oftentimes if you do get a misstep you learn from that mistake and you move on And certainly you want to revisit this process if you add more what we call side hustles Maybe you want to add some different features to your home-based primary care business that can enhance your revenue stream This gives you an opportunity to take that to the next level Lynn since connecticut is your home state. Why don't you Talk well about our friends at Connecticut small business development corporation So i'm not sure if all the small bell small development business corporations in the states are set up like Connecticut is but they have over 18 videos that take you through the process of starting your own business It's a lot of fun to watch and you can learn a lot from them But they have over 18 videos that take you through the process of starting your own business It's actually a tutorial that can take you from a to z they have a lot of online training a lot of opportunities to um connect with people in the score area the retired business executives And there also is opportunities to connect in other states as well. So they have a wealth of resources that are available And there was a contact person there and she really wants contact yes, definitely That brings us to the end of our presentation and we would love to welcome any questions that you might have at this time Okay. Sorry. Thank you. I apologize. Thank you to our presenters, Dr. Rapp-Silver and Ms. Berkowitz, for sharing not only their knowledge and their experiences with us, but just so much great information today. As we move into the virtual office hours, I just want to let everybody know we're also joined by Dr. Thomas Cornwell, HCCI CEO and founder of Home Care Physicians, Dr. Paul Chang, HCCI's Senior Medical and Practice Advisor and Medical Director for Home Care Physicians, and Brianna Plensner, HCCI's Manager for Practice Improvement. We do have a couple of questions that were submitted during the presentation, as well as a few that were received ahead of time. If you have any questions related to home-based primary care, whether clinical or practice management, you can also ask those at this time. We may go over by a couple of minutes today. Usually we are pretty close to 5 o'clock, but I just wanted to let everybody know, just with so much great information, that we may go a little bit over. If you're unable to stay, you can always email your questions in, and we'll give that information before 5 o'clock. In the interim, the questions that I'd like to share with you today, Lynn and Zandy, are one is interested in knowing more about how a small practice can participate in the new payment models and away from fee-for-service. Okay, I'll start with that. I think that is the major challenge for small practices, and I think there are two very distinct views on it. One is that small practices should not mix with downside risk, which is financial risk, which is essentially a penalty if your outcomes for cost and quality fall below your targets. That a small practice should only participate in upside performance payments, which basically is quality outcome reward. I think that's probably the route that most small practices will go through, too, because it is much less risky. But the other path, which we've seen since physicians started organizing in the same way that nurse practitioners and advanced practitioners of all sorts are looking at now, is how do we create leverage with payers? When you consider the Federal Trade Commission antitrust regulations, you can't just be a member of a network that doesn't share clinical data, doesn't share financial data. You need to form an organization that allows you to exchange data and pricing and demonstrate to a payer that you aren't just talking the talk, you can walk the walk. But that involves paying to create an infrastructure that brings you all together to leverage payers. I tend to come from an industry that leans towards the latter approach, but we're just beginning to beat the drum on that. Some of you may have seen that NPEN is currently circulating a survey on value-based payment opportunities and who is participating in what or what support you would need to consider it. I predict that's a biggie. The other thing that I just wanted to add to that also is if you're eligible to participate in the merit-based payment system through Medicare and their quality payment model, you should sign up for that. We do get reimbursement for quality measures that we actually do on a daily basis in taking care of our patients. So, CMS.QPP.gov is really what you need to go on to see if you can participate in that. Perfect. Thank you. We have a question from inside the presentation and it says, hi, Lynn and Sandy, it's Gretchen. Two years in the house calls practice now. So far, plugging my experience into your presentation is pretty spot on. If you need a case study in the future, let me know. My question. I'm way ahead of the business plan now in growth phase. Do you have any presentations for the first growth after establishing the new practice? No, but that doesn't mean we can't create one. We created this one. So challenge us. I mean, I think that's the beauty of... I'm sorry. Go ahead. Go ahead. One of the things that attracts senior nurse practitioners who own practices to NPEN is the commitment that we've made to them as mentors. So they want to be the people that we would go to to say, how did you get from your initial business plan to a scalable model? So that might be an interesting conversation to have. Lynn, did you want to make a comment as well? I was just going to say that part of NPEN's beauty is that we're trying to create a community of entrepreneurs and whatever phase you're in, in that process, we want to create a home base where people feel comfortable asking questions, whether you're somebody who's new starting up or somebody like Gretchen who's out there and she has this wealth of experience that she might be able to support somebody who's new starting. But we also have to make sure that Gretchen gets the support too, because we want to see her to continue to grow and move her practice to the next level. Our next question is kind of a question, kind of a comment. How to match acuity with the intensity of resources? That's always a fun challenge because I think as we move forward, we have to make sure that we're able to take care of the patients that we get assigned to us, that they're in our comfort area. And I think one of the things to make sure is that you have support resources around you that if you're questioning whether or not that patient acuity is right for you, you can actually hopefully tap on some of your resources and make sure that's indeed the case. Also knowing what's involved in your community, because obviously if there's a patient who requires more significant needs, where are you going to send that patient? So I think that's a great question and you really just need to know what's in your community. Sandy and Lynn, this is Brianna from HCCI. Just piggyback comment there. I think the intake process too, like you mentioned, can be very time consuming. So thinking about that from the start, you know, who's going to answer the phone? Are you going to have any nursing triage protocols to determine, you know, if an urgent visit needs to happen? EMR has come a long way with, you know, even risk stratification and looking at your patient's HCC scores, their higher crow condition category scores, and maybe even using some data to look at, you know, your higher acuity patients and making sure they have a more frequent visit intensity than maybe your more stable patients. So there's a lot of strategies that you can put into place, but making sure you've thought through that. That's a good idea. Absolutely. Okay. Next question is, does all insurance panels participate in our calls? What are the preferred ones? I think that might be house calls. I believe it's house calls, I apologize. And before we answer this, we've got about five more minutes. So I just want to make everybody aware of our time. We will finish out our questions and then after the presentation, certainly send out any questions and answers that we may not have gotten to today to all of our attendees. But let me repeat the question one more time, I apologize. Does all insurance panels participate in house calls? What are the preferred ones? So house call reimbursement is the same as office visit reimbursement. So it will be covered under insurance and obviously with any insurance plan you want to make sure that the patient's got current insurance and that they're eligible. So that's the first key is to make sure that you're in your credential with that company so that you can get reimbursement. But again, a lot of these visits may be co-pays or deductibles or co-insurance. And again, the Medicare managed care plans have different sets of criteria too. Brianna, I don't know if you want to chime in on that one as well. Yeah, no, you're exactly right. Just be careful with the Medicaid and if you are taking that managed care plans, you would need to be the primary care provider or at least under the same group that the patient would be assigned to. For some of them could be your only, you know, other concern when you're looking at payment. So just making sure you know what insurances you're taking and that you're monitoring any new plans that you might start working with to make sure you're getting paid. And then the other thing to consider too is that some employers have self-funded plans as well. And this gives the person an opportunity to negotiate the rates a little bit more than if you have a traditional Medicare, Medicaid, or an HMO type plan. So the self-funded ones, you do have to be able to understand how to negotiate. So you really need to be aware of what your costs are. Okay, perfect. Dr. Cornwell had actually wanted to share a slide with everyone. So I'm going to turn it over to him just for a moment. Can you hear me? Can you hear me, Danielle? Yes, perfectly. Okay, great. So this is just a big thank you for the nurse practitioner profession. This is just a slide showing a decade's worth of house calls from 2007 to 2016. And you can see that Redline, who's really coming to the stage with this, with your entrepreneurial spirits are nurse practitioners in terms of really leading the charge for house calls in this country. We are really excited to be working with NPEN. And again, just a big thank you for our speakers as well as to all your great work out there. Thank you. Yeah, I love this slide. Isn't it a great slide? It really is incredibly impressive. I mean, it's just, it's extraordinary. You look, it went from about 230,000 to over 800,000 house calls over this decade, and it continues to rise. Thanks for sharing that. That's, that's very, very exciting. And you're going to share that with us so we can use it? Yeah, I will share. And there's actually, I wasn't going to, but there's also, here's domiciliary visits. These are assisted living facilities and group homes. And it's a very similar picture. Yeah. And yeah, I will email these, I'll email these to you. Great. Thank you. One of the things that we're finding in our ventures with talking with other nurse practitioners is that they really want to go where the patients are. So this is, those two slides really reflect us going to where the patients are. So, thank you for sharing that. And you have permission to share them as, as, as, as able. Okay. Thank you. Great. Thank you guys so much for, for giving us your, your expertise and your experience. Well, we're looking forward to people coming to the conference that we're joint sponsoring in February. So we're hoping to see everybody there. Great. That was actually a perfect tie-in because I was going to remind everybody, as we're wrapping up our webinar today in our virtual office, we want to thank our presenters, Dr. Lynn Brapsilber, Ms. Sandra Berkowitz, as well as Dr. Thomas Cornwell, Dr. Paul Chang and Brianna Plensner for joining us today. And we do have an HCCI and NPEN joint conference in February of 2020 at the Sheridan Crescent in Phoenix. So, if you're new here from the Midwest, Phoenix sounds amazing in February, just put that out there, along with all of the knowledge that you'll gain. I want to remind everybody too about our HCC Intelligence Resource Center. We have a hotline that you can reach out to, as well as an email, help at hccinstitute.org Monday through Friday, nine to five. The webinars every third Wednesday. We provide an advertisement for those on the HCCI homepage, our virtual office hours, which immediately follow the webinars, and then we have some great tools and tip sheets out there that, you know, some wonderful free resources. Our upcoming events, super excited. On December 5th and 6th, we have our advanced applications of home-based primary care, which includes the simulation portion to it. As I mentioned, the HCCI and NPEN joint conference in February of 2020 in Phoenix, Arizona. The essential elements of home-based primary care, March 26th and 27th of next year. And then every third Wednesday of the month, come in, join us for the webinars. We do archive them and you can always view the recording. Wednesday, December 18th, we have managing depressive disorders in homebound patients. And then Wednesday, January 15th, 2020, my goodness, I can't believe we're there already, self-care, avoiding burnout, and maximizing you and your team. Okay, last but certainly not least, our HCCI consulting services. These are definitely relationship-focused and results-driven. So it's another service that we can offer to you where you can get help if you're a provider, if you're a practice manager, if you're another professional. And then here again is the phone number and the email. I'd like to welcome everybody, or excuse me, thank everybody for joining us today, as well as again, Sandy and Lynn from NPEN. It was wonderful to have everyone here with us today. We are just a little over five o'clock, but please remember that there will be a survey going out shortly after the presentation is over. We welcome your feedback, advice for future topics, and wish everybody a wonderful day. Thank you for joining us. Thank you.
Video Summary
The video was a webinar titled "Entrepreneurship: I Want to Start a House Call Program" presented by the National Nurse Practitioner Entrepreneur Network. The presenters discussed the rewards and challenges of starting a house call program and provided tips for success and sustainability. They emphasized the importance of readiness, including personal considerations and financial goals. They also discussed the need to validate the market feasibility and evaluate the practice before opening the doors. Additionally, they mentioned the stages of behavior change and how they relate to the entrepreneurial process. The presenters provided resources available through the Connecticut Small Business Development Corporation and mentioned the importance of branding and marketing your business. They also discussed the need for proper financial planning and revenue cycle management. They concluded the webinar by highlighting the growth of house calls in the nurse practitioner profession and the opportunities for small practices to participate in new payment models.
Keywords
Entrepreneurship
House Call Program
Success and Sustainability
Readiness
Market Feasibility
Practice Evaluation
Stages of Behavior Change
Branding and Marketing
Financial Planning
Payment Models
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