Always Say 'Yes'

Family nurse practitioner Scharmaine Lawson-Baker e-mailed me in early October to say that Sen. John Kerry had mentioned her moments earlier in his remarks to a national conference on e-prescribing. "Hey, that's cool," I replied. "I know!!!!" she wrote back.

Scharmaine (who asked to be referred to by her first name in this profile) radiates the same exclamation point level of excitement when she talks about her practice making house calls to older and disabled, mostly indigent patients in New Orleans. Listeners are drawn to her, and she uses her charisma for good - whether it's finding housing and social services for her patients, arguing for expanded home health privileges for nurse practitioners, or promoting technology changes to the health care system.

Beginning in 2006, Scharmaine became a regular visitor to lawmakers' offices in Louisiana and Washington, D.C., after the Healthcare Information and Management Systems Society (HIMSS) interviewed her about health disparities and technology. She has since told such powerbrokers as Sens. Mary Landrieu, David Vitter, Ted Kennedy and Barack Obama how her PDA was key to getting treatment for her dispersed patients after Hurricane Katrina.

In 2007, Scharmaine convinced CBS to follow up on the continuing health care mess in her city. CBS Evening News anchor and managing editor Katie Couric spent a day following the NP as she made house calls to FEMA trailers. The 4-minute segment emphasized Scharmaine's crucial role as an independent health care professional - and how she is often her patients' only connection to health services.

On a big screen in a packed ballroom a few months later, Scharmaine replayed that TV report for the membership of the American Academy of Nurse Practitioners at the organization's annual conference. Proud colleagues gave her a standing ovation and stood in line for business tips and autographs?.

?But Scharmaine isn't this year's Nurse Practitioner Entrepreneur of the Year because she's a rock star. She is our winner because she survived significant challenges and built a successful business. She turned adversity into advantage - growing her practice, helping her patients and promoting her profession.

Opportunity Knocks

In late 2004, Scharmaine was treating patients in a family practice clinic in New Orleans. A local physician who was retiring asked her to assume the care of 15 homebound patients. Scharmaine had substantial home health experience as an RN, and the idea of providing more comprehensive home care as a nurse practitioner appealed to her. She pitched the idea of adding house calls to her employer, but he rejected the plan.

Yet the idea kept nagging at her. She knew there was a need: A few years earlier, she had tried and failed to find a house calls provider for her grandmother and had to move her to a nursing home. So she researched Medicare reimbursements and the legal aspects of NP-owned practice in Louisiana. She convinced herself she could make a solo house calls practice work.

In March 2005, she opened Advanced Clinical Consultants with $20,000 in personal funds and the most fuel-efficient SUV she could find. She signed on a collaborating physician and began making house calls. "I had no real interest in business as such," Scharmaine recalls. "But before I knew it, I had a business - I was in business!"

Within 3 months, the practice grew from 15 to 100 homebound patients. She had little competition for her patient base in the heart of the city, and Medicare payments were reliable and covering expenses. Scharmaine expected the practice to grow significantly and swiftly.

Mother Nature had plans of her own.

Disaster Strikes

Just 6 months after the launch of Advanced Clinical Consultants, Hurricane Katrina hit the Gulf Coast. Most of Scharmaine's patients were displaced or died in the floods that followed the storm. Using her salvaged PDA, Scharmaine was able to contact many of the patients who had relocated and to send lab tests and drug lists to their new providers across the country - even though she was temporarily transplanted to Texas. Sitting in San Antonio, she feared that her new business was a shambles.

When she returned home in November 2005, though, she found that her practice was needed more than ever. With no hospitals and a mere handful of health care providers, everyone remaining in central New Orleans was a patient who needed a house call.

Displaced physicians asked Scharmaine to check on their former patients. Neighbors buttonholed her after patient visits. Pastors set up clinics for her in their churches. Word spread, and the NP found herself with 300 patients within a few weeks.

She vowed to go anywhere she was needed. At first, this meant visits to crumbling houses on abandoned, debris-filled streets. After several months, it meant visits to the FEMA trailers sitting next to those houses. She created a small network consisting of social workers, a podiatrist, an optometrist and a pharmacist who would see patients at home. She helped patients fill out forms and phoned relief agencies. She was practicing as she'd always wanted to - providing truly holistic care.

Still, she says, there were some "loose ends."

Going Above and Beyond

Scharmaine acknowledges that she has a "fixer" personality. She looks for the root of a problem as the best place to aim the solution. So when one of her new patients developed hypertension that didn't respond to multiple medications, she got on the phone with FEMA and demanded a trailer. Her approach paid off: "Like magic, his blood pressure began to normalize until he was completely weaned from all antihypertensives," she remembers.

Housing for most of her patients was horrible then, and it hasn't improved much since. A house call to one patient would turn up three elderly roommates who had moved in after their own homes were destroyed. With waiting lists full for the few rentals available, Scharmaine believed the best way to find safe housing for her patients was to buy a few buildings herself.

That plan hasn't succeeded - yet. She did purchase an appropriate structure in 2006 and contracted with Catholic Charities and other agencies for group-home status. But she found that her residents had some complaints about sharing spaces. Then there was some damage. Today, the building accommodates her business office, and the housing aspect of hervision is on hold.

The Revised Plan

Life eventually settled into a new normal for New Orleans, but Scharmaine's patients had always been poor and remain that way. Medicare covers house calls, but not necessarily wound care supplies orincontinence pads. Some patients can't afford a prescription copayment. Scharmaine started reaching into her pocket to give $10 here, $20 there.

With nearly 1,000 patients on the roster in 2007, it was clear that handing out cash couldn't continue. Scharmaine wasn't a private charity - but she could start one.

After a few months of confusion over paperwork, she founded Geriatric Initiatives, a nonprofit that formalized her provider network and offers cash and services to older or disabled adults.

"My philosophy is that no one, especially an 85-year-old woman making $300 a month in Social Security Income, should have to decide between purchasing a case of diapers and buying her diabetes pills," she proclaims.

Agency funds can be used to pay utility bills, buy necessities such as food or clothes, or to cover copayments and medical supplies. Geriatric Initiatives also helps eligible clients pay their rent.

The agency's staff of nurses and social workers (part paid, part volunteer) coordinates medical and hospice care and manages social services. The organization hopes to add mental health and dental care providers to the initiative - as well as that elusive housing component.

Business Is Business

Scharmaine says running the nonprofit is similar to, but a bit more intimidating than, running her primary practice. As with any business, paperwork and accounting are essential. But with a nonprofit, the stakes can seem higher, especially in the heightened scrutiny after Hurricane Katrina.

Scharmaine has discovered a talent for turning up resources. AARP now provides two office workers to Geriatric Initiatives for 18 hours a week, and the National Council on Aging supplies eight senior companions whom Geriatric Initiatives can assign to do light housework, cook a meal or just sit and talk with patients.

The NP has also developed some creative revenue strategies for her primary business. A post-storm grant from the state garnered $50,000 on the condition that Scharmaine would continue making house calls in Louisiana through 2011. She agreed, of course.

The practice brings in cash as a certified Medicaid enrollment center. The agency sends a check for every application Scharmaine's staff helps fill out, and the practice enrolls new patients at the same time. The business also participates in the Physician Quality Reporting Initiative, earning incentive payments from the Centers for Medicare and Medicaid Services for sending data about evidence-based practice.

Scharmaine cites constant innovation - acquiring more certifications, purchasing diagnostic equipment, mastering new procedures - as her strategy for staying profitable when her main source of reimbursement is Medicare. Her capstone project for her recently earned doctor of nursing practice degree focused on group visits, and she is working on a plan to implement the model in her home visits.

Labor of Love

Scharmaine draws a salary that is a bit better than average for an NP. She works hard for every dollar and she feels the weight of her responsibilities - for maintaining the practice, for being a role model for her employees and for keeping her patients' stories in front of people who can help.

"Nobody should go into house calls for the money," she emphasizes. "This is not a million-dollar job, and it should be looked at as service to the community that brings you untold nonmonetary rewards."

A patient testimonial expresses best what Scharmaine does for her community - and the nonmonetary rewards she receives as a result.

"I had been writing those FEMA people for months trying to get a trailer," a patient wrote to ADVANCE. "Well, that Scharmaine came right over and made about three phone calls. I had my trailer in 2 weeks, and she got my medicines delivered to my trailer! I just love that girl. She's got some kinda miracle stuff with her."

Jill Rollet is the managing editor and the coordinator of the Entrepreneur of the Year competition.

One to Watch: Michael Lawler, NP

One Business Leads to Another

by Jill Rollet

If you won the lottery today, would you show up for work tomorrow? In 1995, Michael Lawler's answer to that hypothetical question was "No way." Several months out of college and working in a customer service position, Lawler knew his future had to be different from his present. "I needed a career move that meant something to me and was valuable to others," he recalls.

Today Lawler is a family nurse practitioner with four separate but related home health care businesses in Newport, Pa. And while he'd love to win the lottery, he swears his working life wouldn't change much if he did.

Finding His Niche

Following his "lottery moment," Lawler sized up the health care system and concluded that physicians weren't going to maintain their monopoly on basic care. Health care, he believed, was already making room for other types of providers. Of these, the nurse practitioner role drew him for its autonomy and emphasis on critical thinking and for its power to make a difference in people's lives.

Lawler's particular interest in home health care grew out of a class assignment during his NP program. The paper he wrote argued that life shouldn't end in a hospital. Older adults interested in quality of life are frustrated by a system that denies them the option to die at home. Wouldn't a better arrangement be to provide hospital care at home? By graduation, Lawler was working in geriatrics and devising a better way to achieve this goal.

Problems and Solutions

That better way was Angels on Call, started in March 2006, and then Housecalls Rx, which launched a year later. Lawler's spinoff businesses, Home Remedy Skilled Nursing and Care for All Affordable Home Health Care, got under way this fall. Lawler is also developing two products that he hopes to manufacture.

Lawler's businesses have grown organically as solutions to needs that arise on the job. Angels on Call generates the seed money for the other ventures. This wellspring entity employs 70 caregivers who offer living assistance and disease-specific education to about 50 patients. Caregivers provide companionship, do light housekeeping, prepare meals and generally offer nonmedical help to allow patients to continue living at home.

What makes Angels different from other home care agencies, Lawler explains, is that staffers are selected and trained by a health care professional. "There are people who used to own hardware stores who jump into home health," he says, explaining that home health companies are often run by someone with no clinical background. "Why people like me or other providers won't do it isbecause they may feel like they're doing a job that doesn't require their day-to-day [medical] skills."

That hasn't been the case for Lawler, who initially found himself providing prescription refills, basic care and acute care to Angels patients. "I would treat some patients [who] weren't my patients because what it meant to them was they stayed at home," he says.

But Angels wasn't set up to bill for this work, so Lawler was providing care pro bono. The answer was Housecalls Rx, designed to provide medical care to homebound patients. The philosophy behind Housecalls is that patients have the right to live and die in their own home. Lawler's patients typically don't require much preventive care and aren't interested in the latest last-ditch therapies. What they do want is to avoid hospitalization and long-term care facilities.

The initial patient base for Housecalls came from Angels clients, but it has grown to about 200 patients and Lawler is now seeking to hire two more NPs. Home Remedy will hire RNs to provide skilled nursing in patients' homes, and Care for All will contract with independent providers to offer skilled services to Angels and Housecalls patients.

Patients and their families are generally happy to find a provider who will make house calls, and they have no objections to nurse practitioners, Lawler reports. But one of his biggest challenges has been with home health and hospice agencies. "Agencies are willing to work with us, but there is uncertain reluctance. Signing home health orders has been the most difficult re-education," he says.

Business Sense

Before launching Angels on Call, Lawler had no business background. He admits that he's only about a quarter of the way through writing the original business plan. "I'm just now, now, now," he says. "I'm not waiting 6 months because there's another [business] class to take. There's always going to be another class you think you should have."

Despite the nontraditional start, Lawler has earned back his initial investment of $45,000 in credit card advances, the companies are debt free, and his employee retention is high.

Lawler credits his success to the relationships he and his employees have built with patients. "Our office operates on the premise that we need to work with 85-year-old people, not the other way around," he declares.

Outside the Box: Helen Carcio, NP

Restoring Dignity Through Dryness

by Jill Rollet

When Helen Carcio was a girl, her grandmother lived with her family. The beloved matriarch had given birth to 10 children, and as she got older, urinary incontinence became a pervasive problem.

"She always smelled of urine and would leave stains on our furniture," recalls Carcio, now an adult nurse practitioner and continence care expert. "I remember feeling embarrassed to have friends over . They told me my house smelled like kitty litter. If only they knew the real truth!"

Carcio's memories of her grandmother's struggle are what inspire her to teach about incontinence today. The practice she opened in 2005, Health and Continence Institute of New England (HCI), is all about restoring dignity through dryness. Its dual strategy is to provide treatment to patients and to equip other NPs to open continence care centers.

Dispelling Myths

HCI has two components. In the clinical portion, Carcio sees patients 2 days a week, treating about 15 older adults in hour-long sessions. Her 10-step approach to "bladder health" - which she says is easier for patients to talk about than "incontinence" - includes diagnostic testing, behavior modification, pelvic floor rehabilitation, vaginal support devices and medication. She boasts a 50% dry rate and reports that all her patients make progress toward that goal. Her methods are conservative; she has recommended surgery for only 12 of the more than 2,000 patients she has treated.

When she's not seeing patients in her office, Carcio spreads the good news that incontinence is not an inevitable consequence of aging. She reaches potential patients through administrators of long-term care facilities and through community groups and senior centers, where she presents bladder health programs designed to give adults with less severe incontinence tips about bladder irritants and other tools to help them help themselves.

Although she specializes in women's health, Carcio also treats men. In fact, men with urinary incontinence make up about 10% of her practice. Stress incontinence is primarily a women's issue, since it is often the result of childbearing. But overactive bladder and urge incontinence are equal opportunity conditions. If continence services for women are sparse, Carcio says, those for men are even scarcer. Her audiences consist of men and women, making a sensitive and gently humorous delivery important.

Carcio also talks to other health care providers in her community. She says these primary care, urology and women's health professionals are often relieved that someone else is willing to tackle the treatment of incontinence. If that someone is a nurse practitioner known for her teaching abilities, all the better.

Teaching the Teachers

The second component of Carcio's practice is teaching other providers about incontinence and helping them set up bladder health programs of their own. Carcio offers a 2-day seminar on establishing and marketing a bladder center. The seminars take place at HCI in South Deerfield, Mass. About 75% of participants are NPs, and 25% are physicians.

The seminar covers clinical topics such as diagnosis, treatment options, coding and available products. It also addresses business considerations such as grant writing, marketing, and maximizing reimbursement. The$1,500 seminar also entitles attendees to continuing support and advice for 3 months after they start a bladder center, and Carcio sometimes visits the new practices to give hands-on advice.

Ultimate Reward

The take-home message for NPs, Carcio says, is that it's OK to profit from the services they provide. The stereotype of the selfless, serviceable nurse can still make "nurse practitioner entrepreneur" sound contradictory. Get over it, she urges. The aging of the population is a perfect opportunity for NPs to establish themselves as the providers of choice in continence care and aesthetics.

"One could even provide both services in a single practice. Advertise that you have 'both ends covered!'" Carcio jokes.

An average NP-managed bladder health center can bring in more than $200,000 a year, Carcio estimates. HCI grosses about $2,400 per patient, and the charges are typically covered by Medicare and other insurance programs. Patients don't schedule with Carcio for single visits, but rather for six to eight visits over 3 or 4 months.

Carcio raised the start-up funds for HCI with two grants and less than $10,000 of her own money. In the beginning, Carcio ran the business out of two rooms she rented for $500 a month from a primary care office. Three years later, she owns that office building and the primary care practice rents from her.

No matter how lucrative her business, Carcio says her greatest reward is the appreciation of her patients. At the end of her treatment, one patient took the diamond ring off her finger and insisted that Carcio keep it.

"She is a stoic Vermont Yankee and won't take it back," Carcio recalls. "I have it in safe keeping for when her children come looking for it."