Paula Howard found a way, rather late in life, to put her nursing nature to good use.
Dustin Distefano and Jerod Evanich found a way, rather early in life, to be their own bosses and, with their grandparents’ experiences as inspiration, to help people at the same time.
The timing of this odd trio’s venture, blended through a Creighton University program for entrepreneurs, couldn’t be better: Obamacare, the federal health insurance overhaul, now penalizes hospitals if patients go home, get sick and come back to the hospital too soon.
That’s the very thing that Howard, 65; Distefano, 29; and Evanich, 30, want to prevent — not to mention going to the hospital in the first place.
Their business, A Place at Home, offers medical and not-so-medical services to keep people well and delighted to be home.
The combination of today’s aging population and the new federal law is spurring the growth of new companies, like year-old A Place at Home, along with established businesses and efforts by the hospitals themselves to keep people healthy and home.
Once the three founders realized they had common goals, Distefano said, the business partnership has “pretty much been love at first sight.”
A Place at Home was “a wonderful test case” for Creighton’s entrepreneur-assisting Halo Institute, said Taylor Keen, executive director. The program gets its name from investment “angels” who provide financing for startup businesses.
“They had an idea that was born out of personal experience, which is the best thing,” Keen said.
The two plans fit together. The two men had business expertise but not the technical knowledge of nursing and home care. Howard knows nursing but not business.
“They started showing revenues right away and had a full plate before we knew it, and were looking to grow,” Keen said. “It’s an example of what we’re trying to do, to nurture the entrepreneurial spirit in Omaha and in the state.”
Today’s crowded field of elder care includes Omaha’s Home Instead Senior Care, which has 900 franchises in the United States and 15 foreign countries, with thousands of clients receiving nonmedical care. Right at Home, another Omaha franchiser, offers similar services.
The Visiting Nurse Association, in business for 115 years in Omaha, offers what it calls “complete in-home care” and close connections to many of Omaha’s hospitals.
The Affordable Care Act’s emphasis on avoiding hospital readmissions has everyone’s attention, said Ruth Freed, director of clinical alignment at Methodist Health System.
“I don’t know if you’ll see more (such businesses) or whether the market kind of has enough of those in the community,” Freed said.
Methodist’s home health division, for example, refers patients to outside groups such as Home Instead or the Visiting Nurse Association. Hospitals themselves also offer services such as nurses who visit patients in their homes to make sure their care continues.
The Affordable Care Act helped drive efforts to reduce readmissions, Freed said. “But I think hospitals would have begun to do this kind of thing because it’s the right thing to do for the patient. Maybe what the ACA did is just maybe cause us to work a little earlier on it.”
A Place at Home aims to fill gaps among existing services, with the need rising because of the new law and the growing number of senior citizens.
Readmissions cost Medicare patients $26 billion a year, the Robert Wood Johnson Foundation said, estimating that $17 billion of that could be saved if patients got the right care in the first place plus follow-up assistance.
At the same time, a new report from AARP said that the number of people — including family members — available to take care of the elderly will decline in coming decades, making hired help more prevalent.
For each person older than 80 in 2010 there were more than seven people in the 45 to 64 age range of most caregivers. That will decline to fewer than 4 to 1 in 2030 and 3 to 1 by 2050, AARP said, when the United States will have three times as many people over 80 than today.
A Place at Home employs 35 part-time and full-time certified nursing assistants and four part-time registered nurses, besides Howard, who spend as much as 3,000 hours a month with clients.
“We have really melded together,” Howard said, smiling at the two younger men in the one-room office they share at 12925 West Dodge Road. “I think of them as family. They never make me feel old.”
She was a public health nurse decades ago in Connecticut but soon moved to Omaha with her husband, Thomas, a physician. She left work to raise a family, becoming an active volunteer for a wide range of causes in Omaha.
Twelve years ago she rekindled her career, earning a master’s degree and joining her husband’s office. There, she discovered patients struggling with the health care process: following doctors’ orders, asking questions, becoming anxious during checkups, communicating with family members.
“That was the spark,” Howard said. She trained the office staff to make sure patients were following up on the care and instructions they received. Eventually she started a business called My Concierge Nurses, with registered nurses acting as advocates for clients.
But starting the business was slow going. “I’m a nurse,” Howard said. “I’m not a business woman.”
A friend suggested she contact the Halo Institute. There, she met Distefano and Evanich.
The two had been friends since fourth grade, growing up in northwest Omaha. They took different paths as young adults but kept in contact.
Distefano earned a degree in criminal justice and wanted to work with juveniles, but discovered it was difficult for him to take steps that resulted in young people being removed from their families.
He became a management trainee for a telemarketing company, worked for a time in England and then managed an Enterprise auto rental office in Scottsdale, Ariz. When he married, he returned home.
Back in Omaha, he reconnected with Evanich, who had studied real estate and property management and worked as a Realtor.
“I have never wanted to have a boss,” Evanich said, but hoped to run his own company.
Both had grandparents and great-grandparents who had faced old age and medical problems, and things didn’t always turn out for the best. Distefano’s grandmother in Audubon, Iowa, ended up having to spend all her money and leave her home, against her will, to live in a nursing home across the street.
“It didn’t take rocket science to figure out that there must be a better way,” Evanich said. The two worked out a business plan in November 2011. Distefano’s mother-in-law showed him a World-Herald article about the Halo Institute, and the two signed up.
After meeting Howard, the three officially merged in June 2012 and opened Aug. 1 of that year, with each putting up $5,000 for startup costs. Distefano is CEO, Evanich is president and Howard is chief nursing officer.
Their original $5,000 was quickly paid back, but most of the revenue goes back into the business so far. Their monthly salaries have been small.
Howard’s passion is nurse advocacy. Many elderly people don’t have family members who can go with them to doctor appointments.
By working out a personalized plan with the patient and family members (a plan costs $450), the registered nurse can act on behalf of the patient and the family.
“We sit in their place,” Howard said. “We do what they want us to do.”
When staff members first sit down with elderly patients, often there is “a mess of medications,” Evanich said, prescribed by different doctors and sometimes interacting with each other in negative ways. The plan gets the medications in order and properly administered.
With family members on board, the plan can address issues such as nutrition, physical fitness and household needs.
The plan sets personal goals. One client, for example, wanted to live at least five more years, so the plan set out strategies to make that happen. Nurses collaborate with clients’ doctors, making sure decisions are in the patients’ best interests and family members remain in the loop. “We’re that conduit, which is often lacking today,” Howard said.
The company’s registered nurse advocacy includes assessing health and in-home safety, recommending referrals for medical and living needs, telephone communication and coordinated care planning, which includes collaborating with care providers, researching health and wellness options and advocating during medical appointments and emergencies.
Prices include $100 to $150 an hour for in-home or medical visit by a registered nurse, depending on advance notice, and $450 for five hours a month and $850 for 10 hours a month.
A Place at Home offers three levels of in-home service by certified nursing assistants: basic care ($22 an hour) such as light housekeeping, shopping, laundry, house plant care and organization assistance; personal care ($19 an hour) such as bathing, dressing, mobility and meal preparation; and companion care ($19 an hour) including hobby maintenance, church-going, respite care, reading and social media interaction with family.
A Place at Home doesn’t provide skilled care, such as occupational or physical therapy. But the company is licensed by the State Department of Health and Human Services to give medications and other minor medical tasks.
Fees also include $3,000 a week for 24/7 care by certified nursing assistants, $300 a day for a live-in caregiver and $185 for overnight care.
The company also helps with transitions, whether it’s living at home after the death of a spouse or moving into an independent living apartment or an assisted living facility. Some people who move into elder-care housing remain clients afterward.
“Seniors are so worried that they’re not going to have enough money,” Howard said. “We want to be part of the solution.”
The company can explain how clients can pay for the living arrangements they need. For example, filing long-term care insurance claims may help pay for services that can keep them in their homes. Staff members can coach the clients through the claims process, which can be complicated.
Sometimes the health care system can create undue anxiety, Howard said.
A notice from Medicare about a $10,000 medical treatment may state clearly that “This is not a bill,” but the patient may not understand, and the anxiety alone can be damaging.
A Place at Home’s clients come mostly from referrals by doctors’ offices, rehab centers, social workers, case managers and a few from hospitals, plus calls from the company’s advertising and social media outreach.
“Hospitals know about us,” Howard said, but also have other resources for patients.
This year, Medicare withheld nearly $1 million from hospitals in Omaha and Lincoln because of excess readmissions. Potential penalties will increase next year, although readmissions declined in 2012 in part because of the threat of penalties.
Under Obamacare, hospitals also can be penalized because of low patient satisfaction scores. With a nurse advocate, Distefano said, it’s less likely that the patient will end up confused and frustrated with the hospital experience.
Drexel Sibbernsen is one of the company’s first clients, and certified nursing assistant Asha Tolbert is one of its first caregivers. She’s part of a 24/7 team who work with Sibbernsen, a resident of Immanuel Village.
The arrangement works well, Sibbernsen said, especially when he gets a ride to have lunch or supper at the Omaha Country Club, where he is past president. “It’s just marvelous,” he said.
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