Nurse Entrepreneurs: The Real Independent Practice of Nursing by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; Lucille Contreras Sollazzo, BSN, RN-BC, NPD

Nurse Entrepreneurs: The Real Independent Practice of Nursing

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD Lucille Contreras Sollazzo, BSN, RN-BC, NPD

n Abstract General trends in population health are having an impact on healthcare and the role of the registered professional nurse (RN) as a unionized nurse entrepreneur within a social justice system. The aging population and mental health disease in the United States is placing increased demand on healthcare. Between 2010 and 2030, the aged will increase by 75% to 69 million in the United States. One in five Americans will be a senior citizen. In 2050, an estimated 88.5 million in the United States will be aged 65 and older, and by 2060, there will be about 98 million older persons. Statistics indicate that 80% of older adults have at least one chronic condition, while 68% have at least two chronic conditions. An estimated 18.1% (43.6 million) of U.S. adults aged 18 years or older suffer from mental illness, and 4.2% (9.8 million) suffer from a seriously debilitating mental illness. These statistics are driving a paradigm shift in the role of RNs as primary care services suppliers and RN entrepreneurs. Increasing numbers of RNs will be needed to care for the growing number of U.S. adults with chronic conditions and geriatric syndromes. These trends will shape and mold the nurse entrepreneur of the future.

Introduction

A shift is being made from the biomedical model of illness toward population health management by focusing on assessment, prevention, wellness, and chronic disease management. As a result, the demand for primary care services in New York State is projected to rise over the next five years, due largely to population growth and aging, and to a smaller extent, to expanded health insurance and New York’s history as a gateway for immigration into the United States.

Primary care serves four important functions: It enhances access to care for each new medical need; it provides long-term, person-focused (as opposed to disease-focused) care; it facilitates comprehensive care for the majority of a person’s health-related needs; and it integrates coordination of care when it must be sought elsewhere. Currently, the leading causes of illness, disability, and death in New York are largely preventable. Primary care encounters with healthcare providers are important occasions for addressing preventable illnesses, health promotion, disease prevention, and treatment (Epi, 2011). Nurses, in the role of primary care providers and entrepreneurs are uniquely positioned to promote and provide quality primary care within a social justice system by supporting the development of targeted products and services of a direct care, educational, research, administrative, or consultative nature (Vannucci & Weinstein, 2017). Nurses now have the opportunity to move their skill set beyond the bedside, explore entrepreneurship opportunities, and become drivers and leaders in population health management and equal access to healthcare services for all populations. Nurses now have a unique opportunity to focus on alternative, nursedriven detection and prevention models of care that can provide patients (individuals and families) and other clients, such as industries, schools,

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, is currently employed by the New York State Nurses Association as the Director of Nursing Education and Practice. She also held positions at NYSNA as the Director of Labor Education, and as Associate Director in NYSNA's Labor Program. An attorney with over 25 years experience in the field of medical and nursing malpractice, and 30 years as a nursing educator, Dr. Esposito has been adjunct faculty at Adelphi University School of Nursing; Hofstra University; University of Continuing Education; Dowling College; and Excelsior College School of Nursing. She has authored many articles and text materials on subjects of interest to nurses. Lucille Contreras Sollazzo, BSN, RN-BC, NPD, is currently employed by the New York State Nurses Association as the Associate Director of Nursing Education and Practice. She also has held positions at NYSNA as the Associate Director in NYSNA's Labor Program and as a Nursing Representative in the Labor Program. A nurse for over 30 years, she has worked in many specialty areas and has just completed a Master’s Degree in Nursing Education.

corporations, etc., with a higher quality of care and life at more affordable prices, and with quicker access. Recent trends in New York’s healthcare include prohibitive rising healthcare costs, continuous changes in healthcare reimbursement rates and allowances, increases in chronic illnesses, an aging population, increases in inequities and disparities in healthcare delivery, and increases in population diversity (Vannucci & Weinstein, 2017). Nurses, with their distinctive skill set, are exceptionally positioned to create advanced and novel approaches to fill the gaps in primary care services that these trends generate.

Natural Fit for Nurses to Be Entrepreneurs Nursing is, and always has been, an autonomous, self-governing, self-directed profession, and a distinct scientific discipline with many autonomous practice features. In addition to extensive medical expertise, nurses have a unique, holistic, patient-advocacy focus, a unique scope of practice, and a unique body of knowledge, including special expertise in areas such as health promotion, disease prevention, direct care as ordered, consultation, education, research, and advocacy (Keyes, 2018; The Truth About Nursing, 2015). Yet, many nurses have not considered becoming self-employed or entrepreneurs. Furthermore, the general public may not know about or recognize the independent practices of nurses and nursing. Nurses have always been responsible for the education and counseling of individuals, families, communities, and populations. Nurses have always been responsible for supervising other members of the healthcare team. It is precisely because of these independent roles that nurses are suited to venture out and become nurse entrepreneurs (Keyes, 2018).

From the 1940s to the 1970s, the vast majority of nurses were employed by facilities, primarily acute care hospitals. The literature denotes, however, that many nurses have become disenchanted with the restrictions facilities place on nurses’ scope of practice and work, dissatisfied with workplace conditions, and disillusioned with the lack of autonomy the state has given to the profession overall (Sanders & Kingma, 2012).

The Institute of Medicine (2010) recognized the need for nurses to seek unique roles that support a varied scope of practice, thereby filling gaps in healthcare in its report “The Future of Nursing: Leading Change.” The report noted that nurses have a vital contribution to make in building a healthcare system that meets the demands for high-quality, safe, patient-centered, affordable, and accessible care. Health reform is increasingly directed to strengthening the healthcare system as primary care shifts to communities (Campbell, 2016).

As governments struggle with escalating healthcare costs, cutbacks have been used to manage increasing costs, and seem likely to continue. Today’s nurses are in a pivotal position to address healthcare cost issues through varied entrepreneurial options, such as nurse-led clinics for diseases such as diabetes, mellitus, and other chronic illnesses, geriatric care, mental health conditions, and community case management for patients discharged early from hospitals (Sanders & Kingma, 2012).

The Climate of Healthcare Reform in New York and the Nation Supports Nurse Entrepreneurship The Affordable Care Act (ACA), the New York State Delivery System Reform Incentive Payment (DSRIP) Program, and the New York State Nurse Entrepreneurs: The Real Independent Practice of Nursing n

Health Innovation Plan (SHIP) provide opportunities to shift the focus on New York’s healthcare system to promoting health, preventing disease, and encouraging innovative approaches to the delivery and coordination of primary care. The overarching objective of these programs is to have 80% of the state’s population receiving primary care within an advanced primary care setting, rather than relying on emergency departments to be the first stop in meeting healthcare needs. To drive this change, a statewide, multipayer approach that will align care and payment reform is underway. Core objectives of these programs are as follows: • Engage patients as active, informed participants in their own care, and organize structures and workflows to meet the needs of the patient population. • Actively promote the health of both patient panels and communities through screening, prevention, chronic disease management, and promotion of a healthy and safe environment. • Manage and coordinate care across multiple providers and settings by actively tracking the sickest patients, collaborating with providers across the care continuum and broader medical neighborhood including behavioral health, and tracking and optimizing transitions of care. • Promote access as defined by affordability, availability, accessibility, and acceptability of care across all patient populations. (New York State Department of Health, 2017)

Although the need to expand primary care services is widely acknowledged, there is a well-documented concern that primary care practitioners are not well distributed across the state (Center for Health Workforce Studies, 2015). In 2009, 18% of adults (1.1 million New Yorkers) did not have a regular primary care provider (Epi, 2011). As of December 2017, New York State had over 5.8 million individuals living in primary care health professional shortage areas (HPSAs) (Center for Health Workforce Studies, 2018).

In response to the current regulatory changes, anecdotally and through trade publications of specialty nursing associations such as the National Nurses in Business Association, nurse entrepreneurship is on the rise. A nurse entrepreneur is considered to be a “proprietor of a business that offers nursing services of a direct care, educational, research, administrative or consultative nature” (International Council of Nurses, 2004, p.4). The importance of social support, membership, and networking through nurses associations, mentorship from association peers, and marketing strategy are reportedly the top items associated with successful nurse entrepreneurs providing direct care as independent practitioners or within nurse-led group practices offering case management, product development, consulting, or educational services (Vannucci & Weinstein, 2017).

Nursing’s Transforming Role to Entrepreneur and the Future Need of the Nursing Workforce The 2016-2026 U.S. Bureau of Labor Statistics employment projections describe occupational demand for RNs. It projected that while the average growth rate and need for all other occupations is 7%, the projected percent change for RNs from 2016-2026 will be 15%. The projected numeric need from 2016-2026 is calculated to be 438,100 practitioners needed to replace those who leave the occupation or retire. Recent research indicates that,

overall, there will be a shortage of 154,018 RNs by 2020, and 510,394 RNs by 2030.

In order to deliver safe, quality, patient-centered, accessible, and affordable healthcare to our growing and aging population, nursing services must be delivered dramatically differently at the individual and systems levels. The focus of healthcare must shift from illness to one that prioritizes wellness and prevention, environmental and social triggers of preventable disease conditions, and education. The focus of nursing practice must, therefore, shift from caring only for the current event in the hospital or office to creating care plans and services that maximize a person’s wellness (Salmond & Echaverria, 2017).

These requirements have driven changes in the academic and clinical training programs to support the development of nurse leadership and entrepreneurship competencies (Carlson, 2015; Keyes, 2018).

New York’s Aging Population Is Underinsured and Suffers from Chronic Health Conditions

Life expectancy in New York increased citywide to 81.2 years in 2015, a jump of 1.5 years since 2006. Among the 1.1 million residents over the age of 65 in New York City, there are more than 1.6 women for every man, making older women one of the city’s fastest-growing demographics (Messina, 2018). New York State residents are aging so rapidly that it has the fourtholdest population in the nation, with 3.7 million people aged 60 and over. New York’s aging population trails California, Florida, and Texas. According to the NYS Office for the Aging, by 2030, 5.2 million people in the state will be aged 60 and older. Of that group, 1.81 million New Yorkers will be aged 75 or older. This will increase the number of older New Yorkers to one in four (Campaneli, 2017) (see Table 1).

Table 1 New York State Population Trends

Population Trends 2000 2008 2010 2015 2020 2025 2030 Total Population 19,000,136 19,460,969 19,566,610 19,892,438 20,266,341 20,693,354 21,195,944 Ages 5 and over 17,763,021 18,216,035 18,314,451 18,619,147 18,985,180 19,398,722 19,874,195 Ages 60 and over 3,211,738 3,558,460 3,677,891 4,027,480 4,499,549 4,962,734 5,302,667 Ages 65 and over 2,452,931 2,559,826 2,588,024 2,851,524 3,191,141 3,615,695 4,020,308 Ages 75 and over 1,180,878 1,281,459 1,259,873 1,242,577 1,332,145 1,561,652 1,815,879 Ages 85 and over 314,771 403,129 417,164 442,958 454,298 486,682 566,423 Ages 60-74 2,030,860 2,277,001 2,418,018 2,784,903 3,167,404 3,401,082 3,486,788 Ages 75-84 866,107 878,330 842,709 799,619 877,847 1,074,970 1,249,456

Minority Elderly, 60 and over Ages 65 and over Ages 75 and over 736,742 981,360 1,062,919 1,277,197 1,552,380 1,865,871 2,180,775 506,282 674,022 716,078 872,889 1,058,974 1,296,349 1,574,537 196,537 285,885 303,764 357,680 426,448 537,061 672,261

Disabled (ages 5 and over) 3,606,192 3,784,789 3,831,083 3,952,167 4,096,932 4,253,663 4,400,598 Ages 5-17 257,194 246,675 244,978 246,999 252,089 255,876 260,507 Ages 18-59 2,206,913 2,206,913 2,210,226 2,198,510 2,161,587 2,141,246 2,156,392 Ages 60 and over 1,201,431 1,331,201 1,375,879 1,506,658 1,683,257 1,856,532 1,983,699

Poverty, (1) age 60+ Below 150% Below 250% 352,835 652,365 1,201,110

Note: Association on Aging in New York. (2019). Retrieved from http://www.agingny.org/Portals/13/External%20Documents/NYSAC%20Presentation%201.30.18.pdf

The Health Workforce Analysis Guide (HWAG) (2016) indicates that the state’s total population is over 19 million, while New York City has a total population of 8,128,980. Statistically, 18% of city residents are without health insurance and the city has a total emergency room (ED) visits per 10,000 population of 3,480,700. New York City adult residents suffer from chronic conditions, including hypertension (9%), diabetes (9.6%), asthma (9.3%), obesity (21.3%), poor physical health (10%), and poor mental health (9.2%).

Compared to the population of 65 and older statewide (14.3%), the Long Island Region, including Nassau and Suffolk counties, has an even higher percentage of elderly (15.4%). Total numbers of the elderly on Long Island exceed 439,500. Similar to the Mohawk Valley Region and Central New York, Long Island has a higher total death rate per 100,000 total population than the state average, and higher rates of death due to heart disease and all cancers (Center for Health Workforce Studies, 2018). The Mohawk Valley Region also has a much higher rate of deaths due to diabetes per 100,000 total population than the state as a whole. Additionally, the rates of total hospitalizations, preventable hospitalizations, and hospitalizations due to chronic lower respiratory disease per 10,000 total population are all higher than state averages (Center for Health Workforce Studies, 2018).

The North Country Region has a higher total deaths rate per 100,000 total population than the state as a whole, as well as a higher rate of deaths due to cancer and diabetes. The North Country also has a higher rate of hospitalizations due to chronic lower respiratory disease per 10,000 total population, than the statewide average.

Those age 65 and older in the Capital District region have a higher total rate of deaths due to all types of cancer per 100,000 total population than the state as a whole. The Finger Lakes Region has higher rates of total deaths, infant deaths, and deaths due to all cancers per 100,000 population than New York State as a whole (Center for Health Workforce Studies, 2018). The Southern Tier region has higher rates of total deaths, deaths due to heart disease, deaths due to cancer, and deaths due to diabetes per 100,000 total population than statewide averages. In addition, the Southern Tier has greater rates of ED visits and preventable hospitalizations per 100,000 total population than New York State as a whole (Center for Health Workforce Studies, 2018).

New York’s Population Suffers from Mental Health Conditions

Every year, more than one in five New Yorkers has symptoms of a mental disorder, and in any year, one in ten adults and children experience mental health challenges serious enough to affect functioning in work, family, and school life. The disease burden exceeds that caused by all cancers combined (NYSDOH, 2011). Mental disorders that appear early on, when left untreated, are associated with disability, lack of success in school, teenage childbearing, unstable employment, marital instability, death by suicide, and violence. An estimated 18.1% (43.6 million) of U.S. adults aged 18 years or older suffer from mental illness, and 4.2% (9.8 million) suffer from a seriously debilitating mental illness (HRSA, 2017).

Neuropsychiatric disorders are the leading cause of disability in the United States, accounting for 18.7% of all years of life lost to disability Nurse Entrepreneurs: The Real Independent Practice of Nursing n

and premature mortality. Moreover, suicide is the 10th leading cause of death in the United States, accounting for the deaths of approximately 43,000 Americans in 2014 (Healthypeople.org, 2018). A New York State law mandating for mental health education to become part of K-12 curricula throughout schools statewide was set to take effect in July 2018 (MHANYS, 2018). New York is the first of two states in the country, along with Virginia, to pass this type of law. According to the Bureau of Health Workforce, New York has 159 total mental HPSA designations and is experiencing a shortage of 57.57% practitioners needed to remove the HPSA designations (HRSA, 2017).

Physical and Mental Health of New York State Residents Drive Healthcare Transformation

Chronic physical and mental health conditions are singled out as the major cause of illness, disability, and death in the United States (Salmond & Echevarria, 2017). It is estimated that the cost of chronic conditions will reach $864 billion by 2040, with chronic conditions among older adults being more costly, disabling, and difficult to treat—despite being the most preventable. Based upon these population statistics and current technological trends, RNs may find themselves spending more time in consulting, educating, and chronic care management roles outside of the acute care center, as politicians and healthcare corporations push for more of the in-house acute care monitoring of patients to be done by technology such as smart beds, telemedicine, and robotics (Keyes, 2018).

Populations Trends Drive Healthcare Transformation and Social Justice Entrepreneurship

Social justice entrepreneurship focuses on the social mission of the entrepreneur and the attempts to develop a business, not only for economical purposes, but mainly for a social purpose. Social justice entrepreneurs use available resources to facilitate innovative ideas and opportunities that are seen as an answer to the needs of the market and that can also produce social change while developing and improving societies. The social justice entrepreneur, as an agent of change, adopts a mission to create and sustain social value, recognize and relentlessly pursue new opportunities to serve that mission, engage in a process of continuous innovation, adaptation, and learning, and act boldly without being limited by resources currently in hand. Social justice entrepreneurs will demonstrate a heightened sense of accountability to the constituencies served and for the proposed outcomes (Mihalcea, Mitan, & Vitelar, 2012).

New York’s population trends coincide with the need for a new type of nurse social justice entrepreneur and a new nurse-led primary care business model. According to the U.S. Census Bureau, all but two counties in New York (both Upstate) have lost population through domestic migration (the movement of residents to other states and counties). Population loss is accelerating in Suffolk County, New York’s largest county outside New York City. Higher domestic migration (up 15% in the past year), a lower birth rate (down 4%), and an increase in the death rate (up 4%) among county residents is driving the trend. The biggest population losses since the last decennial census have been in the Upstate rural counties of Delaware, Hamilton, Schoharie, and Tioga (Empire Center, 2017) (see Figure 1).

Figure 1. Net domestic migration 2010 to 2016 showing that recruiting and retaining New York’s aged population is essential for New York’s economic development and maintaining healthy societies.

New York State’s governor, Andrew Cuomo, has declared that attracting and retaining the elderly and retirees in New York State has become the new export industry of the region, similar to tourism. It is estimated that the over-50 population accounts for a majority of the spending in several categories of goods and services, including healthcare. Direct spending on consumer goods and services, including healthcare, by those ages 50 and over amounted to $5.6 trillion in 2015. Forty one percent of state and local tax revenue has been attributed to consumers over the age of 50 (New York State Association of Counties, 2018). Continuing trends of domestic migration, therefore, would threaten the economic growth and development of the state.

Governor Cuomo has articulated his vision for how New York’s policies, programs, and initiatives can support the goal of becoming the first age-friendly state in the nation. In support of this vision, the governor established a Prevention Agenda 2013-2018, steered by an Ad Hoc Leadership Group that includes the New York State Nurses Association. Five priorities are identified in the agenda: • Prevention of chronic diseases; • promotion of healthy and safe environments; • promotion of healthy women, infants, and children; • promotion of mental health and preventing substance abuse; and • prevention of HIV, sexually transmitted diseases, vaccine-preventable diseases, and healthcare-associated infections. (New York State Association of Counties, 2018)

To support New York State’s commitment in creating age-friendly communities, the state has set a goal of making 50% of all health systems age friendly within the next five years, which includes the establishment of age-friendly primary care facilities that will be better equipped to provide care to aging New Yorkers with cognitive and other physical and mental disabilities (New York State Association of Counties, 2018).

Scope of Entrepreneurial Options Since a nurse entrepreneur is considered to be a “proprietor of a business that offers nursing services of a direct care, educational, research, administrative or consultative nature” (International Council of Nurses, 2004, p.4), RNs may practice independently, in nurse-led agencies, in collaboration with other healthcare practitioners as their clients, or under the supervision of a physician, nurse practitioner, midwife, dentist, podiatrist clinical nurse specialist, or another APRN. An RN in New York is legally authorized to practice independently and provide the following types of services (New York State Board of Nursing, May 2017): • Perform physical exams and patient assessments to identify and address health problems and unmet patient care needs. • Develop comprehensive nursing care plans and perform nursing interventions to address symptoms, including, but not limited to • grieving •disturbed body image • social isolation • labile emotional control • anxiety • fear • ineffective coping/defensive coping • hopelessness • impaired parenting • impaired resilience • spiritual distress • stress overload

• Perform medical treatments (e.g., medication administration, wound care, ostomy care) as prescribed by a collaborating physician, dentist, nurse practitioner, physician assistant, specialist assistant, midwife, or podiatrist. • Provide health teaching and emotional support to help patients and their families adjust to or manage serious or chronic illnesses or injuries. • Supervise care delivered by other healthcare personnel, such as licensed practical nurses, EMTs, Paramedics, and home health aides. • Work with collaborating physicians and other healthcare practitioners to ensure that patients receive appropriate, timely, well-coordinated care. • Conduct health screenings to detect and address signs of early disease or

risk factors for disease and then provide health teaching or make referrals as appropriate. Other entrepreneurial services might include (Sanders & Kingma, 2012):

• Development, assessment, and sale of healthcare products and devices; • legal nurse consultive services; • healthcare/policy consultation and publications; and • educational and consultative services.

The nurse entrepreneur can assume a multitude of roles directly linked with the professional and business aspects of a practice (Sanders & Kingma, 2012) (see Figure 2).

Roles of nurses in entrepreneurship

Supervisor/Owner

Case Manager

Researcher

Therapist

Consultant

Educator

Clinician

Figure 2. Roles of nurses in entrepreneurship adapted from Sanders & Kingma, 2012

There are several options for nurses who want to start their own businesses and become independent practitioners. In the many roles noted in Figure 2, nurse entrepreneurs can provide a wide range of services, whether they work for someone else or as an RN owner of a company/ partnership providing the services (see Table 2).

Table 2 Entrepreneurial Options

Entrepreneurial Option Included Services The Client

Home Care chronic care management; services for maintaining flexibility, strength, and balance to keep family member in the home longer; physical therapy for stroke/accident victims MD, hospital, home care agencies, insurance companies, individuals, families Immunization Nurse provision of immunizations schools, MD, government agencies Staffing/Recruitment Agency/Private Duty Registry providing per diem nurses hospitals, home care agencies, schools, private corporations, individuals, families, over-55 community boards Lactation/Lamaze Consultant providing breastfeeding and child birth information insurance companies, hospitals, MD offices, expecting couples Holistic Nurse assessment of overall wellness, nutrition counseling, acupuncture, massage therapy, reflexology, reiki, crystal therapy, sound therapy, medical qui gong, yoga, meditation individuals, families, private corporations Enterostomal Therapy provision of enterostomal care, nutrition counseling, mobility counseling, teaching insurance companies, hospitals, home care agencies, individuals, families Wound Care provision of wound care, nutrition counseling, mobility counseling, teaching insurance companies, hospitals, home care agencies, individuals, families Foot Care provision of foot care, nutrition counseling, mobility counseling, teaching, reflexology insurance companies, hospitals, home care agencies, individuals, families Infusion/IV Therapy maintenance of bleeding disorders (hemophilia), autoimmune diseases (MS, neuropathies) insurance companies, MDs, individuals, families Wellness Coach education, assessments, nutrition counseling, exercise planning insurance companies, individuals, families, RN owners Legal Nurse Consultant reviewing cases to determine if standards of practice were adhered to and if a case is viable insurance companies, law firms, DAs, hospitals, government agencies Sexual Assault Nurse Examiner gather evidence to substantiate civil and/or criminal actions government agencies, law firms, hospitals, insurance companies, individuals Life Care Planner work with people who have catastrophic injuries and chronic health conditions (chronic pain, immune disorders) law firms, insurance companies, HMOs, government agencies Case Management, Patient Advocate accompany patients to MD visits, consultative services, insurance navigation, community services navigation, coordination of services insurance companies, individuals, families Case Management: Disease Care Manager education, assessment, care planning, individual patient care insurance companies, government agencies, individuals, families, RN owners Case Management: Geriatric Care Management/ Senior Citizen Care Consultant education, assessment, care planning, individual patient care preventing falls, home modification, strengthening exercises, nutrition consultation, video/telephone monitoring, chronic disease assessments, home visits individuals, families Family Nurse Consultant education, assessment, care planning, individual patient care preventing falls, home modification individuals, families

Table 2 Entrepreneurial Options, (con’t)

Nurse Educator: Public interpreting research literature, validity of commercial information, how to search for reliable information, health coaching, community lecturer, occupational health consultant, management consultant, human resources consultant, prevention programs TV, radio, Internet Nurse Educator: Chronic Care Management preventing exacerbations of asthma/COPD, diabetes, coronary artery disease, arthritis, spinal cord injury, heart attack, congestive heart failure, depression, allergies insurance companies, government agencies, individuals, families Nurse Educator: Illness Prevention preventing STDs, flu, lice, providing telehealth services schools, government agencies, individuals, families

Nurse Educator: Educational Company create continuing education products schools, hospitals, MD offices, libraries, individual practitioners, nursing associations Nurse Medical Sales Consultant selling medical equipment to be used in hospitals or other healthcare settings, schools, private corporations, selling wellness products, cosmetics, health foods, nutritional supplements independent practitioners, pharmaceutical companies, insurance companies, medical devices companies Psychiatric Mental Health Nurse depression screening, suicide screening, resilience training, work with people to develop social support system, communication skills, mental health education, therapeutic alliance with patients, emotional regulation skills such as meditation and mindfulness individuals, families, hospitals, MDs, schools Adult/Child Day Care Facility high-quality day care corporate firms, hospitals, attorneys, schools Researcher projects aimed at improving health services/status of a target population corporate firms, hospitals, attorneys, schools

Note: Table showing RN entrepreneurial options, compiled from Keyes, 2018; National Nurses in Business Association, 2018; Sanders & Kingma, 2012; Whelan, 2012

Benefits of Nurse Entrepreneurship Research cites many benefits of nurse entrepreneurship. Vannucci and Weinstein (2017) indicate that nurse entrepreneurs gain psychological empowerment (having a meaning/purpose and impact on the public), personal growth, opportunities for independent decision-making, autonomy, and better self-care skills from their independent practices. Solesvik (2013) identifies economic benefits derived from entrepreneurial activities, the possibility of achieving independence, and achieving specific goals as benefits of entrepreneurship. Other studies show that the need for a flexible work schedule, ability to follow ideas, and having more earnings as reasons for nurse entrepreneurship (Jahani & Fallahi, 2014). Eddy and Stellefson (2009) identified the authority to use personal style and creative flair to carry out a task or to produce free from the policy and procedural constraints of large organizations as a benefit of entrepreneurship. Whatever the benefits of nurse entrepreneurship, today’s nurses have additional opportunities to be innovative and influence the direction of healthcare. The time is ripe, and the time is now for nurses to consider whether an entrepreneurial role could be a good next step in their healthcare career.

The Future of Nursing and Reimbursement Opportunities for RNs The need for nurses to seek unique roles that support a wide scope of practice and which fill gaps in healthcare is recognized in the 2010 Institute of Medicine report. Innovative and creative healthcare provided by entrepreneurial nurses across all health settings is one way of expanding the human influence of innovative healthcare (Wilson, Whitaker, & Whitford, 2012).

The Balanced Budget Act of 1997 allowed for third-party payments, such as Medicare, to be paid to nursing entrepreneurs. In addition, New York State Insurance Law, Chapter 996 (1984) provides that every insurer issuing a group policy for delivery of health services in New York and every health service or medical expense indemnity corporation issuing a group contract or a group remittance contract in New York must make available coverage for the services of a duly licensed RN acting within the lawful scope of his/her practice if the services of the RN have been negotiated as being reimbursable under the contract of insurance. This means that

insurance companies are legally required to reimburse for nursing services when the contract between the insurer and the provider of the insurance negotiate for nursing services.

Home and office visits, often included in comprehensive coverage such as major medical insurance, are the types of independent RN services envisioned under this legislation. Under a contract providing coverage for home and office visits, the insured would be entitled to coverage for services provided by RNs in the home or in a nurse’s office as long as the service provided is within the lawful scope of practice of the nurse and negotiated under the contract. Chapter 996 is a freedom of choice provision that is intended to provide coverage for nursing services in lieu of physician services. Rates for the nursing coverage may vary depending upon the existing benefits of any given contract to which the “make available” nursing benefit rider may be attached (New York State Department of Financial Services, 1985) (see Notice Provision 1). When the make available nursing benefit has been added to coverage, an insurer cannot limit reimbursement to the RN by making coverage for the services provided by the nurse available only upon the certification or the recommendation of a physician of the need for the nursing services.

Some Examples of Reimbursement Opportunities Under CPT Codes

CPT Code 9211 As professions grow and mature, they often expand or adjust their scope of practice to reflect current public needs, clinical realities, professional priorities, and/or fiscal necessities (HWAG, 2016). To meet the present-day primary care needs of patients, the Centers for Medicare & Medicaid Services (CMS) has created new payment codes for care coordination activities that are performed by independently or intradependently practicing RNs that ultimately result in reduced costs and improved patient outcomes. An RN can bill under code 99211 as an “office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician to perform or supervise these services” when the presenting problems are minimal, and typically five minutes are spent performing the services.

The average unadjusted 2004 payment from Medicare for a 99211 service is $21. This would equate to only five 99211 encounters with Medicare patients in a week producing a $5,000 per year income for a The time is now for nurses to consider whether an entrepreneurial role could be a good next step in their healthcare career.

practice. A 99211 office visit does not have any specific key-component documentation requirements (Hill, 2004). Basic guidelines for a 99211 service are as follows: • The patient must be established. According to CPT, an established patient is one who has received professional services from the physician or NP or PA within the past three (3) years. Code 99211 cannot be reported for services provided to patients who are new. • The RN provider-patient encounter must be face-to-face. For this reason, telephone calls with patients do not meet the requirements for reporting 99211. • An Evaluation and Management (E/M) service must be provided. Generally, this means that the patient’s history is reviewed, a limited physical assessment is performed by the RN, or some degree of decision-making occurs. If a clinical assessment/need cannot be substantiated, 99211 should not be reported. For example, 99211 would not be appropriate when a patient comes into the office just to pick up a routine prescription. • The presence of an MD/NP/PA is not always required. CPT’s intent with the code is to provide a mechanism to report services rendered by other individuals (such as a nurse or other clinical staff member in a nurse-led practice). According to CPT, the staff member may communicate with the collaborating APRN or physician, but direct intervention by the collaborating practitioner is not required.

Some examples of billing for a 99211 include asymptomatic urine STD screening, stand-alone HIV counseling and testing, chlamydia treatment with a previously written order, or retesting after treatment for chlamydia or gonorrhea (STD TAC, 2014), monthly B-12 injections, suture removal, dressing changes, allergy injections, and peak flow meter instruction (Hill, 2004).

Notice Provision 1: The home care mandate found in the Insurance Law requires that the home care must be provided by a certified home health agency possessing a valid certificate of approval issued pursuant to Article 36 of the Public Health Law. In addition, the Plan covering the home health service must be established and approved in writing by a physician. The general freedom of choice provision found in Chapter 996 does not supersede the specific requirements incorporated in the home care legislation identifying criteria which must be satisfied in order to qualify for reimbursement.

CPT Codes 98966-98968 Additionally, an RN who is collaborating with a physician’s or APRN’s group can bill under codes 98966-98968 for non-face-to-face telephone Nurse Entrepreneurs: The Real Independent Practice of Nursing n

services and clinical discussions for assessment and disease management services (Hertz, 2009). These services are denoted as follows:

Procedure Code Type of Service Provided

Procedure Code 98966

Procedure Code 98967

Procedure Code 98968 Telephone assessment and management service provided by a qualified non-physician healthcare professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion Telephone assessment and management service provided by a qualified non-physician healthcare professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion Telephone assessment and management service provided by a qualified non-physician healthcare professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

CPT Codes 99487-99489 Codes 99487, 99488, and 99489 are additional codes that an RN can bill under. Code 99487 should be used if non-physician staff members, such as nurse navigators, spend more than an hour in 30 days coordinating care for a patient. Code 99488 covers the same amount of care coordination, but also includes a meeting in person, and 99489 covers additional time spent coordinating care over one hour, in 30-minute periods.

HCPCS Procedure & Supply Code S9123

Some patients with complex medical diagnoses can now remain at home with the support of skilled nursing care. This care is different than general home health care, which is usually managed by intermittent, brief visits by skilled staff. Skilled hourly nursing care or medically intensive home nursing care refers to complex hourly nursing services provided by an RN in the patient’s home for more than four hours per day. Using code S9123, services are reimbursable if the nursing services are ordered by a licensed physician (MD or DO) as part of a treatment plan for a covered medical condition; there is a physician approved, written treatment plan with specific short- and long-term goals; the nursing services provided are reasonable and necessary for the care of a patient’s illness or particular medical needs; the services provided are within the accepted standards of nursing practice; and the patient’s condition requires frequent nursing assessments and changes in the plan of care that could not be met through an intermittent skilled nursing visit, but only through skilled hourly nursing services. Services that are reimbursed include: • Assessments (e.g., respiratory assessment, patency of airway, vital signs, feeding assessment, seizure activity, hydration, level of consciousness, constant observation for comfort and pain management);

• administration of treatment related to technological dependence (e.g., ventilator, tracheostomy, bi-level positive airway pressure [Bi-PAP], intravenous [IV] administration of medications and fluids, feeding pumps, nasal stents, central lines, dialysis); • monitoring and maintaining parameters/machinery (e.g., oximetry, blood pressure, end tidal CO 2 levels, ventilator settings, humidification systems, fluid balance, etc.); and • interventions (e.g., medications, suctioning, IVs, hyperalimentation, enteral feeds, ostomy care, and tracheostomy care).

CPT Codes 99490, 99487, 99489, and G9506 Chronic care management services are reimbursable to RNs under CPT codes 99490, 99487, 99489, and G9506 for providing interdisciplinary team care. Some of the services that are reimbursed include the following (see Table 3):

• Use of a certified electronic health record (EHR) • Continuity of care with designated care team member • Comprehensive care management and care planning • Transitional care management • Coordination with home- and community-based clinical service providers • 24/7 access to address urgent needs • Enhanced communication (for example, email) • Advance consent

(Department of Health and Human Services, 2016)

Table 3 Summary of 2017 CCM Coding Changes

Billing Code Payment (Nonfacility Rate) Clinical Staff Time Care Planning Billing Practitioner Work CCM (CPT 99490) $43 20 minutes or more of clinical staff time in qualifying services Established, implemented, revised, or monitored Ongoing oversight, direction and management Assumes 15 minutes of work Complex CCM (CPT 99487) $94 60 minutes Established or substantially revised Ongoing oversight, direction, and management + medical decision-making of moderatehigh complexity Assumes 26 minutes of work Complex CCM Add-On (CPT 99489 use with 99487) $47 Each additional 30 minutes of clinical staff time Established or substantially revised Ongoing oversight, direction, and management + medical decision making of moderatehigh complexity Assumes 13 minutes of work CCM Initating Visit* $44-$209 -- -- Usual face-to-face work required by the billed initiating visit code Add-On to CCM Initiating Visit (G0506) $64 N/A Established Personally performs extensive assessment and CCM care planning beyond the usual effort described by the separately billable CCM initiating visit

Note: Department of Health and and Human Services. Centers for Medicare & Medicaid Services. (2016). Chronic care management services changes for 2017. Medicare Learning Network, citing CPT only copyright 2016 American Medical Association. Retrived from http://www.cms.gov/Outreach-and-Education/Medicare-Learning

Next Steps in Becoming a Nurse Entrepreneur in New York State

A nurse-led entrepreneurial enterprise in healthcare is worth exploring. Nationwide spending on health is projected to grow at an average rate of 5.5% annually and is projected to account for nearly 20% of the nation’s gross domestic product (GDP) through 2026. According to the U.S. Bureau of Labor Statistics, employment in healthcare-related occupations is projected to grow 18% from 2016-2026, much faster than the average for all occupations. Additionally, nearly half of the 20 occupations projected to have the highest percentage increase in employment through 2026 are in the healthcare industry (Lesonsky, 2018).

Nurse entrepreneurship is a growing segment of the healthcare industry right now. If starting your own business or expanding your nursing talents into an innovative new way of caring for patients is something you’re interested in, now is a good time to start. But before you spend any time or money on a new service, product or idea, start reading everything you can about nurses who run their own companies and what it’s like to start your own business. Learn about the education or training they received, the financial investment they made, the return on investment they received, and the time commitment it all took. Perhaps most critical at the start of your enterprise is a clear evaluation of what your business will be, who your customers will be, and whether there is a real need for what you will be offering. Next steps might include: • Determining what your niche and expertise is that is exciting and gratifying for you; • developing relationships with nurse practitioners and doctors pertaining to that specialty who are in their own practice or with a healthcare facility; • negotiating rates with insurance companies for reimbursement; • researching billing websites that would work for you; • setting up a system (computer software) to track patient outcomes; • maintaining BCLS and other certifications that are required for the work you are doing;

• looking into additional insurance coverage to protect your business and yourself; • taking some continuing education or college courses on business; • determining the taxation status that is best for your business (Corporation, LLC, Proprietor); • networking and look in to nursing entrepreneur organizations; and • thinking about advertising and what would be best for your business.

Conclusion

As a nurse, your self-employment and business options are unlimited. Your new job may not bear any resemblance to your old nursing job, but it will certainly build on your nursing knowledge and skills. It’s an empowering thing to say you are the owner of your own business. People pay attention. What will really matter, though, is not being a CEO of your Nurse Entrepreneurs: The Real Independent Practice of Nursing n

own company as much as the kind of CEO you are. That’s what clients will remember.

Nurses are facing a world in which global changes are affecting our industry and profession. There are opportunities for innovation that did not previously exist. There are opportunities for independent practice, private practice, joint ventures with physicians or other health professionals, consultancies, staffing businesses, or invention of a new piece of equipment for patient care. Most of all, there are opportunities for personal and professional growth (Sanders & Kingma, 2012).

As the demand for cost-effective, high-quality healthcare services increases, the career opportunities and employment options available to nurses continue to expand. The profession’s challenge is to recognize and seize these opportunities and to continue to create new and vital roles for nurses within the healthcare industry while maintaining high-quality caring functions that are at the heart of nursing (Sanders & Kingma, 2012).

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