One Specialty at a Time

Some HMEs may see the current regulatory climate as an opportune time to cash in and get out, but NBN Group is looking at the situation with a different view — toward expansion. The Philadelphia-area company is opening its sixth branch this year. And what’s driving the company’s growth, its managers say, is meeting local patient needs.

“I think, historically, most companies have expanded geographically,” says CEO Linda Begley, “but, for the most part, they provide the same services or products. We’ve chosen to become a regional company only providing services in [portions of] New Jersey, Delaware and Pennsylvania” that make up the Philadelphia metro area.

The business strategy has allowed NBN to expand horizontally and take advantage of synergies in offering specialized services across the home care sector for both children and adults. “It’s one phone call,” Begley adds. “It should be easier for [patients] to deal with us than another company that doesn’t provide all the services [we do].”

The business has come a long way since Begley founded a private-duty nursing company called Newborn Nurses in 1986. Today, her firm employs more than 200, generates $10 million in annual revenue and has offerings in several highly specialized sectors of home care.

NBN Group serves as an umbrella corporation for divisions that each focus on a separate home care niche: NBN Infusions serves home infusion patients; NBN Respiratory & DME handles everything from pediatric home ventilation to home oxygen clients; New Behavioral Health offers counseling services for children, many of whom are chronically ill; and Newborn Nurses, the division that started it all, still serves the area with private-duty nursing.

Business Opportunity

In the mid-1980s, Begley participated in a historic event at the Children’s Hospital of Philadelphia: She helped discharge the very first ventilator-dependant child home from the hospital. The hospital’s medical director was a visionary, she says, and a few years later became somewhat of a celebrity. Dr. C. Everett Koop, who saw one of the first children go home on breathing support, went on to become U.S. Surgeon General.

With the possibilities of pediatric home ventilation, Begley says she recognized an entirely new health care niche that needed a company to support it, one very specialized that required a work force with an understanding of both the patient and the high-tech equipment involved. So she went out on her own, launching Newborn Nurses in Cherry Hill, N.J.

For the first two years, the company offered private-duty nursing services providing specialized, hands-on pediatric care to new moms and babies. Contacts from the hospital and elsewhere helped Begley bring the right people onboard, and the small company thrived. She then invested money from the successful startup in a not-so-simple field: home infusion.

“Newborn Nurses was a very successful company,” NBN Group COO Joe Boeptcher explains. “That company was the company that built NBN Infusions.”

Many providers shy away from infusion because of the steep startup costs. An infusion patient can cost a company “anywhere from $20 to $1,500 each,” Boeptcher says. “There’s a large capital outlay … Our clean room alone cost about $60,000.”

Staffing is no easy task either. “It’s tough to find a pharmacist with mixing experience,” he explains.

To find the right personnel, Begley again used her contacts at the hospital and put networking into high gear. “We try to be creative in recruiting,” she says. “Once you establish a relationship with clinicians who specialize in a particular area, they tend to network for you. You can obtain good talent that way. People tend to want to work with people whom they respect.”

Proving Its Worth

To break into the infusion market, the company also capitalized on its pediatric expertise. No company in the area specialized in home infusion for children, so NBN filled the need.

But being successful in a new niche is never easy. Begley says referral sources have, at times, tested the company’s service. “Typically when you are new on the scene, referrals will call on you at 5:30 p.m. on Fridays or 7 p.m. on Saturdays to see how you’re going to respond. They test you to see what services you can do as a provider. Once we responded well, the referrals did come in … and we eventually found our way.”

For home infusion, after-hour calls didn’t only come on nights and weekends. “I remember leaving my family going to Christmas Eve mass because I had to staff a case,” Begley recalls. “It involved a baby on an IV, and the parents wanted their baby home for Christmas. We got the job done — that’s home care.”

Begley also says in the early 1990s a new, but regrettable, opportunity arose for NBN’s infusion business: home therapy for children infected with HIV. Although treatment of pediatric HIV has changed over the years, the service the company offered then showed referral sources, “Look at us; we can do this,” she says.

In 1990, NBN moved into DME for the same reasons it moved into infusion — because local demand called for it, and providing equipment complemented existing services. “Because most of the [local] equipment companies didn’t really have state-of-the-art pediatric equipment — apnea monitors, for example — we decided to target that audience,” Begley explains. “In those days, there were no pediatric equipment companies. There were larger companies that offered pediatric equipment, but they didn’t specialize in it. That’s where we found our opportunities.”

The company already had the clinical expertise in personnel who had dealt with children on home ventilation and IV, but the area lacked top-notch service for the highly specialized equipment. “Pediatric [respiratory] equipment is different,” Begley says, requiring respiratory therapists with a pediatric specialty who can train children and parents to use the life-sustaining products.

The launch of NBN Respiratory & DME was driven by technology that no competitor at the time was offering — but no insurer was paying for, either. The company had to educate payers to prove that the new technology not only gave better care but also was more cost-effective than alternatives. “We had to go to the insurance companies and demonstrate the equipment to prove there was no way we could provide high-tech service based on the [current] reimbursements but that it was still cost-effective for [patients] to have this care in the home,” Begley says.

Since, the company has added more respiratory services and has recently entered the respiratory medication business, despite Medicare reimbursement cuts. “We already have an infusion pharmacy. Everything was already in place to handle other medications, including albuterol and ipratropium,” explains Jann Sherin, a respiratory therapist for the company. “Why not do it?”

Right Niche, Right Time

NBN’s nursing division has produced much of the revenue for most of the company’s history, but that trend is changing. Five years ago, NBN Infusions and NBN Respiratory & DME collectively produced only a quarter of annual revenue. Today, they provide almost half.

The company has evolved into a multifaceted home care business. The launch of New Behavioral Network in 1998, another niche expansion, took NBN to where few home care companies go. “It seemed at the time a perfect segue into providing another pediatric service,” Begley says. “We were providing nursing for medically fragile children. Now we were able to provide services to behaviorally challenged children. And some of the children who are medically fragile also have behavioral problems.”

For each niche, the company got its foot in the door by providing a pediatric specialty no one else offered. But over the years the company has taken on more adult customers, a move that has produced its most dramatic revenue growth in recent years, particularly with home oxygen therapy. Adult patients may soon outnumber children, according to company managers.

And the company is looking to grow further — to rehab and mobility. But as before, NBN managers are waiting until they have the right personnel in place, and waiting for the right time before making the plunge.

By finding the right people and getting into the right niche at the right time, Begley says the company has become a place where the nurse works with the equipment specialist, the behavior specialist and the pharmacist — all of whom, she adds, provide “quality and continuity of patient care.”

Good People, Good Training

To make sure she is hiring the right people, NBN founder Linda Begley says she has always paid as much attention to character as she has to experience and education. During interviews, she asks a question that usually brings character front-and-center: “Why do you work?”

But after so many years in the business, “we can now hire by reputation,” Begley says. “We’re very fortunate to be able to recruit excellent clinicians who enjoy the ability to work for a small organization.”

That reputation comes from a hefty investment in employee training. Besides offering communication workshops and mentoring programs, the company also conducts periodic performance reviews of customer service. The planning coordinators who answer the phone represent the most important link in the communication process, Begley explains. Once the planner hangs up, he communicates with all of the company divisions involved, from nursing to the equipment warehouse. With any glitch comes a refinement of protocols.

“We have various indicators that we select to focus on throughout the year,” she says. “For example, we have an indicator for deliveries. If a delivery is made to a patient, and the delivery is missing something, we identify the problem and try to target where the error was made, be it customer service in taking the order, or even a driver leaving [equipment] in the car. We then conduct additional training and track the problem. Within three months we aim for 100-percent error-free deliveries.”

Care Coordination

For patients coming home from the hospital, NBN follows a detailed procedure to coordinate its services with equipment needs and make the transition between institutional and home care as smooth as possible. Director of Operations Kelly Begley describes the process for a pediatric respiratory patient.

• As company liaison, Begley meets with hospital staff and the family needing home care services, and shows them two comprehensive lists: one of all home care companies and another of HME suppliers in the area that offer the services they need. (“We happen to fall on both lists,” she says.)
• If the family chooses NBN, Begley collects information on the family and patient. She shares that information with NBN Respiratory & DME division staffers, who ensure necessary equipment is in stock.
• The company’s nursing supervisor meets with the family and, from this point, serves as care coordinator. After a care plan has been developed, a respiratory therapist (RT) refines the equipment list.
• Before the pediatric patient arrives home, the RT helps organize the child’s room for the equipment, and the nursing supervisor identifies staff with the appropriate skills to work with the child and the family caregiver(s).
• When the child comes home, the RT and nursing supervisor visit every day for a week to make certain the transition of care goes as planned.
• As continuing in-home care begins, both the supervisor and the child’s RT monitor the situation for any changes in care that may be needed, and meet periodically “to ensure they’re on the same page,” Begley explains.