Are you a hygienist who wants to work independently & are interested in EPP? (Note: it is no longer called a “LAP”; it is instead an EPP -Expanded Practice Permit.) Do you see my website and go…”oh, I want to do what she is doing!”, “I want to work independently of a dentist!”, “I want to own my own business!” This blog is for you!
After getting umpteen numbers of phone calls, emails, and other contacts from hygienists & hygiene students all around Oregon, I’ve decided I need to blog about how to work independently, as a hygienist in Oregon.
As much as I would love to mentor you guys, I don’t have the time or bandwidth, so please don’t call me and ask me to walk you through this process! But I will give you some tips and starting points to direct you toward working independently.
First off: have you joined ADHA/ODHA (American/Oregon Dental Hygiene Association)? If you haven’t, really, you need to. If it weren’t for people like Lynn Ironside, an ardent ADHA/ODHA member and fabulous Government Relations Council Chair, NONE OF YOU would have the advantages and benefits of our license that we have here in Oregon. So you need to become a member and come to all our conferences! ODHA has a ton of conferences that helps you as a hygienist whether you are a hygienist working in a dentist office or one that works out in the field independently, or all the other myriad ways hygienists work in the world today (public health, research, education, advocate, etc..). Every May ODHA sponsors and puts on a conference JUST FOR YOU, the Expanded Practice Dental Hygiene Conference. Every year is a different set of classes that address topics hygienists normally don’t have any clue about: business planning, marketing, all the ways EPDH’s work, how we work, where we work, networking, clinical concerns (have you considered how you would deal with a medical emergency if you are in the field?), you name it, we have had a class in it. Take advantage of this fabulous opportunity of how ODHA can make your life easier!!
OK, now that you have attended some of the conferences and you have a little better idea of what you want and how you want it, what is next?
Read your State of Oregon Board of Dentistry Practice Act. You will have to do this to get your EPDH (if you don’t have it already, that is) and it will tell you exactly what you can and cannot do with your new permit. You will want to know early on if you plan on working with a collaborative agreement with a dentist or not. (And if you don’t know what a collaborative agreement is, read the Practice Act to find out!) P.S. you can find the practice act online on the Oregon Board of Dentistry website.
My number one advice is this:
Create a business plan. I was lucky that we were made to create a business plan when I was in hygiene school. My school paved the way for us to get our EPDH’s upon graduation and licensure (due to the efforts of both Lisa Rowley and Lynn Ironside, among others) and part of the curriculum was a business class! Most of my classmates just dreamed up their plans as they assumed they would work for a dentist, but I decided to use the opportunity to create my REAL BUSINESS PLAN with 2 other students and my professor critiqued it! Yay! So I graduated from school with a plan that had the input of 3 other people beside myself and that served me very well indeed. What makes up a business plan? Without creating a whole class on the subject, here are the essential components of a business plan:
• Mission statement and/or vision statement. Exactly what area will you target for working independently? Babies? Children? Low income? Underserved populations (which ones)? Seniors? Developmentally disabled children/adults? Mentally ill? Prison inmates? Homeless? What is your niche? Is anyone else in your area filling this?
• Description of your company and service
• Description of how your service is different
• Will you have a collaborative agreement with a dentist? Describe how this relationship will work.
• Market analysis that discusses the market, competitors (anyone else doing what you are doing where you plan to do it?), where you fit, and what type of market share you believe you can secure;
• Description of your management team, including the experience of key team members and previous successes. While you say you are going to do it “all” on your own, consider what it means to do your own accounting, marketing, etc. Really? At a minimum you need to have a lawyer, a CPA and a bank.
• How you plan to market your service;
• Analysis of your company’s strengths, weaknesses, opportunities, and threat, which will show that you’re realistic and have considered opportunities and challenges;
• Develop a cash flow statement so you understand what your needs are now and will be in the future. Don’t underestimate the costs of doing business. It is more than just buying some equipment and going at it! You need insurance, you need to belong to several organizations to network (think ADHA, Chamber of Commerce, etc.), permits, licenses, State of Oregon business registration fees, -you name it. You won’t believe how much it costs just to have a shingle!
• Revenue projections –otherwise known as “how do you plan on getting paid”.
• Summary/conclusion that wraps everything together (this also could be an executive summary at the beginning of the plan).
And before you go….”yeah, yeah, yeah, I’ll do that later!” note that I couldn’t open my business account at the bank without my business plan, I couldn’t talk to my lawyer without my business plan, …well, you get the idea. It all starts with a business plan. If you feel this is all way too daunting, go visit your local community college business department, your chamber of commerce, your small business administration, your local business start-up organization that helps nurture new entrepreneurs in your area and they will help you step through all the steps.
Whew! That seemed hard, didn’t it? Ahhh, that is only the beginning!
You need to register with the Fed’s for your tax ID number (EIN), you will want to get your NPI (National Provider Identifier), and consider being a Medicaid provider (DMAP). You may need to get credentialed with insurance companies and with dental care organizations. EIN & NPI are easy; you just go to the websites and register. All the others take a lot of paperwork and a lot of patience. It can take MONTHS to get your DMAP and some organizations take months to get credentialed. Get used to paperwork, follow-up, hurry-up, more paperwork and WAITING.
Next: OK, here is the fun part; you get to pick your equipment! Price it out, decide what you need now and what you can buy later. Will you have your own sterilizer? Or will you “borrow” your dentist’s sterilizer? Will you have your own room in your house to store all your equipment, have a sterilizing area (clean/dirty), a desk for all the paperwork, cabinets for your files, and laptop for your business? My advice is to start small and work up. It is easy to spend $5K, $10K, and up to $50K on mobile equipment, vans, RV’s, you name it before you have done all your homework on how to make it all pay for itself. But ultimately only YOU can decide what you can live with or without. After you start seeing your patients you will understand exactly what you need. It is easy to buy too much too soon. I’ve heard numerous hygienists start out with $10K (or more) of equipment and after a few months realize they only use a fraction of what they purchased! Arrrg!! That isn’t a smart way to spend your money!
Are you a good speaker? You better be! You will be asked to speak at all kinds of places. It is how you grow your business. You speak at Chamber of Commerce events, you speak at Skilled Nursing Care facilities, you speak at schools, you speak at conferences, you speak to your fellow hygienists, you create classes for caregivers, or CNA’s, or for fellow health professionals, or to the general public such as at health fairs, senior events, diabetes clinics, children at school,….get the idea? I give 1-2 talks a month and I have about a dozen different slide shows for different audiences and for different time slots (2 hours, one hour and 30 minutes). Some discuss oral health and systemic health, some are about basic mouth care, some are for hygienists in how to work in the field, some are for people who have no idea they need to know about what you know! Hate to talk? Freeze at the thought of speaking in front of people? Then join toastmasters to help you get over your fears. You will not be successful unless you can talk about your business. Oh, by the way, be able to describe your business in 30 seconds or what is called “the elevator speech”. You want to be able to tell people what you do quickly and succinctly, the time it takes to take an elevator.
Next: Repeat after me: it takes three years. Repeat after me: it takes three years. What am I talking about? It takes three years to build a hygiene business that starts paying for itself and paying you. And those are hard years of pounding the pavement, knocking on doors and getting doors slammed in your face. Toughen up your skin baby; you are going to need it! Don’t assume you will make a ton of money out of the gate. You won’t. It takes about three years to build your business. Three years before people start referring you to their patients, clients, friends, and loved ones. Three years before all your hard work starts paying off. Don’t expect to get rich. You aren’t doing this to get rich.
Accounting: Do you know Quickbooks? Consider taking a class at your local community college in bookkeeping and in software. Or will you hire someone to do this for you?
When you decide on your lawyer and CPA, make a list of all your questions. You will be paying them to answer your questions by the hour, so make the most of it! Don’t forget your bank, they are another resource too.
Marketing: you will need business cards, brochures, a website, Facebook page, blog, twitter page. Are you on LinkedIn? Social networking is just one of your marketing tools as well as joining every organization that might be able to help you or network you. What about advertising? How much are you willing to spend? It costs a lot of money to advertise and it takes a long time to reap the benefits from advertising. Spend your money wisely. It is all about the plan.
Have you talked to all the dentists & hygienist in your town or area? Do they know what you are trying to do? They should! You want them to refer their patients to you depending on what service you are trying to provide. Have you talked to your local Department of Public Health? They are both another resource and a potential business opportunity to tap into.
Below are questions I have gotten from hygienists & students over that last year that I have collected and answered:
1. How many years after you received your Dental Hygiene License did you apply for the Expanded Practice Permit (EPP)?
Don’t make assumptions about years. I received my LAP permit 6 months after graduation. New graduates from Pacific receive it upon getting their initial license if they want it.
2. Why did you decide to become an Expanded Practice Dental Hygienist (EPDH)? Please provide specifics if you can.
I’ve always had a passion for public health and this is an extension of that. It is also a “tight” market for dental hygiene and I had a mix of experiences as a temp. I didn’t want to have to compromise patient care because of a dentist or a dental group if I didn’t agree with their practices. Being on my own means I can practice dental hygiene as I was taught and using my own critical thinking, not as it is practiced in the “real world” by the dentists supervising the hygienists. Some dentists are great and some are considerably less so.
3. How did you learn about the EPP? Did you practice with Limited Access Permit as well?
I graduated from Pacific University. They emphasize the LAP/Expanded Practice work. LAP was just the earlier form of EPP with a few small exceptions. Anyone with an LAP automatically had their EPP when it changed over.
4. What does it take, or what advice can you offer, about starting to practicing independently apart from what it identified on the EPP application? (2,500+ clinical practice, active BLS/CPR, 40 hours approved CE, and Professional Liability). Please provide specifics if you can.
Pacific University made it easy as by graduating from there, we are automatically eligible for the LAP/EPDH permit, given the number of hours of rotation at various sites.
You have to be a “self-starter” and be strongly self-motivated or you won’t survive. You can’t be afraid of putting yourself “out there” and talking, talking, talking to people one-on-one, in interviews, in groups and giving presentations to large groups. Most people have never heard of such a thing and you have to teach the world what you do.
5. How much does it cost to get a business license? Is it required to practice?
It only costs about $100 to register your business with the state. I wouldn’t practice without it! It allows me to register as an LLC which helps protect my home assets. It also protects my name and my business name. In fact without registering my business name, ANYONE could just “take it” from me. I’ve worked hard to create a “brand”, why would I want someone else to steal it from me? I don’t know if it is a LAW, but I sure can’t see having a business without registering with the state. There are too many advantages.
6. Can you offer any business advice?
HAVE A BUSINESS PLAN! We were required to create one in school. Most people just made it up because they weren’t planning to use it. I DID plan on using mine, so I created it with the intention of actually using it while I was in school. It helps clarify exactly what you want to do, who you want to serve, how to get paid, and how to grow, accounting, marketing, etc. It isn’t written in stone, but it gives you a roadmap of how to proceed. It makes you think about how to do business. While I’ve made a few deviations, it still “holds water” for the most part.
7. Where do you practice and what underserved population(s) do you treat?
Right now, 90% of my client base is seniors that are unable to access dental care due to physical or mental disability and are in long term care of some sort. I have also been working in schools for sealants for 1st graders (Oregon Health Authority) and I work at a dentist office part time as well.
I recently became a provider for E.N.D.S. (exceptional needs dental service) which took about 6 months due to all the paperwork, becoming Medicaid provider, and credentialing with Willamette Dental, Capitol Dental and Managed Dental Care of Oregon.
I am also working with my marketing to help the developmental disabled as well.
8. Could you describe, in as much detail as possible (including treatment protocols, operatory set up, sterilization, patient forms and paperwork, information you give to the patients), how you are utilizing your EPP?
Wow, could you ask for more in one “question”? That is about a dozen questions in one! This could be a book in itself. I will keep it to a couple of paragraphs.
Well, generally speaking, I look at the risks: Caries &/or Periodontal disease. I screen for oral cancer. For the most part I’m unable to do perio-pocket charting because patients won’t allow it (not with severe dementia). You only have a few minutes to do the most good as fast as possible. I rarely do any root planning (SRP). My goal is generally to try to maintain status (perio maintenance or prophy), but if the family or caregivers are motivated I can see great improvements in both perio issues as well as reducing caries risks. I do palliative care which is all about addressing pain, infection and preventative treatments. I customize treatments based on what the patient needs, what the patient can handle and what the caregiver is willing to do. I have many “tips and tricks” for the caregiver to make their job EASIER, not harder. If it is harder, it won’t happen. And I always refer the patient – either to their own dentist, a new dentist, or to whomever it makes sense for them to see. About half the time they are able to get to the dentist, and about half the time they aren’t. Depends on the severity of what I see and how hard I will emphasize the need. I want my patients to see a dentist once a year for an exam and x-rays. That doesn’t always happen. If I think the neglect borders on abuse (broken/bombed out teeth, pain and infection and not going in to see a dentist) then I will do all I can in my power to help the family get their loved one to see a dentist.
Everything I need is in a plastic tote that I pull in my foldable cart. I wipe down whatever table they have plus my equipment and my tote. I have “clean” boxes and I have “dirty” boxes when I’m on the road. I converted my 3rd bathroom into a sterilization room with a clean and dirty side. I purchased an ultrasonic instrument cleaner, a sterilizer and a cordless prophy handpiece.
I took the “best” paperwork I’ve seen used by others and created my own for HIPPA, patient information, health hx, medications, and charts. If there is a prescription, I call it in to the pharmacy. You can go to my website for some of this information.
9. If you wouldn’t mind sharing, how much were your start-up costs and what did they entail? If you feel comfortable, could you please provide specifics? I would greatly appreciate the insight.
It depends on what you already have and what you need!! Every hygienist needs to figure it out and for whom they are taking care of. For me, it was about $3,000 for bare minimum costs, but start-up costs are only the beginning. You have ongoing costs too. It only cost me a couple hundred dollars to convert my bathroom. I already had some equipment, instrument sets and supplies. -Do you need a vehicle? Some people want a van. I didn’t. Some people want the full set up of dental chair, stool, ultrasonic scaler, suction, hand piece, etc. which costs THOUSANDS of dollars-I didn’t (and you need some of this if you are going to do sealants for children). Do you want to take x-rays? That alone will cost you about $8-9,000 dollars. The lowest price sterilizer is $700. But you could spend $5K easy. I know one hygienist who was able to borrow her dentist’s sterilizer. Re: chairs: Most my patients can’t transfer anyway, so I just work on them in their wheelchair, which makes me more portable. Everything I use is pretty much hand instruments. I do have a self-contained cavitron and a small suction machine which I use quite infrequently since most my patients have choking risks. I have a portable, battery hand piece for polishing. You have to spend money on insurance, on business cards, on brochures, on association fees (i.e. chamber of commerce), and on advertising, etc. I am lucky that my husband is an “IT” guy, he helped create my website and web presence. I got that all for free! I have no idea how much that would cost in the real world. I used to work in accounting and I have a background in graphic design, so I used my own experience for that. My weakest link has been marketing, but I’ve actually been doing a pretty good job of it! But do you need to hire an attorney? Do you need to hire a marketing/graphic arts person? Do you need a web designer? Do you need an accountant? Do you want to hire someone for insurance? Do you want to take some business classes? Do you want to network with other business people? Do you want to join associations that will help your business grow? Do you want to be at health fairs with a booth? How do you plan on reaching your target market? What about advertising? Do you want to hire an assistant? That all costs money that isn’t “clinic” related. You better figure it out!
10. If you have a collaborative agreement with (a) dentist(s), what does it entail? What services can you provide within this agreement?
I do not have a collaborative agreement. This means I can’t write a prescription for pre-meds, prescribe anti-inflammatory meds, restore teeth or use local anesthesia. Since I don’t do much SRP, that isn’t a problem and if they need a pre-med, their doctor can write the prescription. I don’t want to restore teeth. I don’t see the great need an agreement for myself. I think it would just make the doctor nervous. Again, this depends on what you are trying to do and who you are trying to help and to what degree. I wouldn’t really feel comfortable doing anesthesia when I’m by myself as over 50% of all medical emergencies have to do with giving anesthesia as well as my patient population is mostly severely compromised. It is a risk I’m not willing to take, to be honest.
11. For the services you provide, what do you charge for each of them? Please provide a specific list if you can and feel comfortable doing so.
I charge $120 per hour for my services. Since 90% of my clients do not have insurance anyway, it works out. If they need me to spend more time because they are more difficult, my time is paid for. If they are “easy”, then I spend less time. I think it works better than “fee for service”, because I will automatically add fluoride varnish if I think that patient needs it. We don’t have to dicker about what services to add or not – it is simple and easy for the families to understand. And it makes my treatment planning easier – I can do what I think is best for the patient.
For Medicaid/ENDS I am working under a contract with them for my services, which is fee for service.
12. Do you choose to bill insurance for the services you provide? If so, what are the obstacles, if any, have you run into when attempted to bill insurance? Any advice that you would like to share in regards to insurance?
I don’t bill insurance. If the families want, I will give them the form for my services so they can get reimbursed. It can take me 8 hours on the phone to get paid for one hour of service and it doesn’t make sense. I’m not an insurance expert. Maybe I will change, but for now that is what it is.
13. Any other advice or specific details that you would like to share? Any information would be greatly appreciated.
Have a business plan! That is the number one advice I would give!
Ann Ossinger is a Registered Dental Hygienist who owns DoorStep DentalHygiene, LLC, a mobile dental hygiene service that provides dental hygiene services to people who would otherwise be unable to go to a regular dental clinic in the Linn-Benton Counties of Oregon. 541-990-0814. Please contact Ann if you have any questions!