Ambulanter Pflegedienst: How to start your ambulatory (outpatient) care service

Contents

• Introduction
• Legal forms
• Prerequisites
• Health & nursing insurance
• Registrations
• Staffing
• Required expertise

 

 

 

Introduction

Operating an independent private ambulatory care or outpatient care service is a task that bears great responsibility; the health and well-being of your patients must be your top priority at all times.

Legal forms for ambulatory care businesses

If you want to start a business, you first have to choose a legal company form. Several legal forms are worth considering when it comes to nursing care services, such as UGs, GmbHs and GbRs. Be sure to take the differences in taxation into account when making your decision. We’ve put together a quick overview of some suitable legal forms for your independent nursing service (Ambulanter Pflegedienst):

UG (haftungsbeschränkt)

A UG – Unternehmergesellschaft (haftungsbeschränkt) – is a type of GmbH. It is especially suitable for those looking to start a private nursing care service with limited liability and without a large amount of seed capital.

Advantages: Forming a UG requires only one euro to start. The total costs of opening a UG are lower than those of a GmbH.

Liability: A UG is a company with limited liability, meaning that only the company’s assets are at risks, not its shareholders’ private assets.

GmbH

Shareholders of a GmbH – Gesellschaft mit beschränkter Haftung – are required to put forward at least €25,000 in share capital to get started.

Advantages: The GmbH is a very popular and highly regarded legal company form both within Germany and abroad.

Liability: In general, GmbH shareholders aren’t personally liable for the company. Only the company’s assets are at risk.

If you want to find out more about forming a UG (haftungsbeschränkt) or GmbH, we have a checklist that goes through every step of how to form a limited liability company in Germany.

GbR

A GbR – short for Gesellschaft bürgerlichen Rechts – is a type of partnership where each partner is a managing partner.

Advantages: No capital or notary services are required to get started.

Liability: GbR partners are personally liable, risking their private assets.

What prerequisites do I have to meet to start an ambulatory care service?

Licences for ambulatory or outpatient care services

The legal definition of an Ambulanter Pflegedienst is laid out in SGB XI (Book XI of the German social code). According to article 71, these services must be independently administrated by organisations that provide nursing care services (under the constant management of trained nursing professionals) to those in need of nursing care in their own homes.

No nurses, no service

If you start a nursing service, you must either be or employ a trained nursing professional. To obtain authorisation to operate, you have to have completed training as a health care worker, a nurse or a pediatric or geriatric nurse.

You must also be able to demonstrate two years of practical work experience in the field you trained in (gathered within the past eight years).

There may be different or additional obligations to meet depending on how many patients are in your care. If you primarily serve disabled patients, for example, trained occupational therapists or specialised care practitioners (Heilerzieher) can also count as qualified nursing personnel in many cases.

Do I need to undergo training in patient care management?

In addition to the aforementioned requirements for ambulatory nursing services, either you or a nursing professional whom you’ve employed must complete training in patient care management, referred to in German as Pflegedienstleitung (PDL).

Although PDL isn’t legally protected as a job title, there are recognized PDL training courses consisting of at least 460 hours of instruction.

PDL training courses focus on topics such as patient care organisation, quality management, personnel management, business administration and law, among others. The courses are often offered by private training institutes.

As an alternative, you may also study patient care organisation (Pflegemanagement) at a technical college (Fachhochschule) to obtain the necessary approval. At the moment, there is no university degree required to pursue a job in patient care management.

In many cases, the finer details of the qualifications required in Germany differ from federal state to federal state. Be sure to contact the relevant agencies and associations in your area to make sure you are thoroughly informed.

Getting approval: Health and nursing insurance

Independent nursing services must apply for approval to operate. During the approval process, your application will be reviewed to ensure that all technical and economic requirements for operating a nursing care organisation are met. The application must be submitted to the nursing insurance company (Pflegekasse) responsible for your business.

Many state nursing insurance associations provide downloadable checklists of the documents you must include in your application – be sure to take advantage of them when available. A similar application must be submitted to the relevant health insurance company (Krankenkasse).

Helpful points of contact also include the representative offices for the Verband der Angestellten Krankenkassen (an association of employee health insurance providers), the Verband der gesetzlichen Krankenkassen (an association of statutory health insurance providers), and the Verband der Ersatzkassen (an association of alternative health insurance providers).

Qualitative requirements

Assessors from the supervisory authority Medizinischen Dienstes der Krankenversicherung (Health Insurance Medical Service), or MDK, regularly inspect nursing services and organisations (often as part of the approval process) to ensure that quality standards are upheld.

The MDK began publishing the results of their quality inspections in 2009 in order to make their criteria measurable, transparent and comparable. This enables those in need of nursing care and their relatives to make informed decisions.

Ambulatory nursing services are evaluated according to these quality standards (Qualitätsprüfungsrichtlinien – QPR). Your ambulatory care service will be evaluated regularly and without prior notice. A report from the Landesverbände der Pflegekassen will follow. If any qualitative deficiencies are determined, a deadline will be set by which the deficiencies must be corrected.

Interpersonal requirements

In addition to professional skills, a patient care manager must also possess interpersonal and social skills. A willingness to learn, empathy, reliability and a high level of patient engagement are just some of the ‘soft skills’ necessary for getting your Ambulanter Pflegedienst business off the ground successfully.

Your organisational and communication skills will provide a vital link between your patients and their relatives, doctors and insurers.

Legal framework

To fulfil the requirements for operating an Ambulanter Pflegedienst, you must comply with the following laws and regulations, among others:

• Framework agreements and federal recommendations for providing home nursing care according to § 132 of SGB V
• Framework agreements and federal recommendations for nursing care according to § 75 of SGB XI
• Nursing Care Quality Assurance Act (Pflege-Qualitätssicherungsgesetz)
• Federal Social Assistance Act (Bundessozialhilfegesetz)
• Infection Prevention Act (Infektionsschutzgesetz)
• Healthcare training and examination regulations

You should have extensive knowledge of all regulations and laws that are relevant for establishing and operating your Ambulanter Pflegedienst.

Service contracts

According to the German Social Code, a so-called ‘social contract’ exists between nursing insurance providers and the providers of public or private nursing services. The contract allows your ambulatory nursing service to provide care to the patients they insure, regulating the conditions (type and scope of care) under which patient care can be provided.

Without a social contract, you cannot provide care to patients insured by those providers.

Where do I need to register my ambulatory care service?

You’ll have to register your ambulatory nursing service with various agencies and institutions both during and after establishing it. We’ve put together an overview of the different types of registrations below.

Business registration

Regardless of whether you choose a limited liability company or GbR legal form for your business, you must register your business with the trade office (Gewerbeamt) responsible for your registered location. After registration, your local tax office (Finanzamt) will contact you automatically for tax registration. As soon as your documents are reviewed by the tax office, you’ll receive your tax number with which you can send invoices.

Public health department

Regardless of where your nursing service is located, you have to register with your local public health department (Gesundheitsamt) in addition to registering with your trade office. You may also be required to submit additional health and police clearance certificates for your employees.

Commercial register (Handelsregister)

Companies with the legal forms UG and GmbH must be entered into the Handelsregister – a public index of registered merchants under the jurisdiction of their respective registry court.

IHK

Your trade office will inform the IHK (chamber of industry and commerce), which will then send you all the necessary documents. A membership with your local IHK is mandatory when registering your trade.

Trade insurance institutions (Berufsgenossenschaften)

Berufsgenossenschaften (Trade insurance institutions) are the carriers of Germany’s statutory accident insurance for companies and their employees. Be sure to register independently with the Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (social accident insurance institution for health and welfare services).

If you’re not sure which of the many institutions you should register with, you can contact the German Statutory Accident Insurance umbrella association DGUV (Deutsche Gesetzliche Unfallversicherung) at +49 800 60 50 40 4.

Federal association of private social service providers (BPA)

As the owner of an independent ambulatory nursing service, you have the option to become a member of the BPA, which is the Deutscher Bundesverband privater Anbieter sozialer Dienste (federal association of private social service providers). The BPA represents the interests of its members publicly, politically and when dealing with payers.

Where should my nursing service be located?

It is especially important to perform extensive research when deciding on a location for your ambulatory nursing service. The presence of competition and the number of potential patients are vital factors that should play a huge part in your decision.

You should be able to answer the following fundamental questions:

• How many competitors are operating in the area?
• Where are my competitors located?
• What services do my competitors offer?
• How many people does each of my competitors employ?
• Who are my target groups?
• How large will my service area radius be?

A detailed analysis of your competitors and their services and catchment areas will help you gather ideas for the structure of your own ambulatory service. It can also help you identify which submarkets are not yet saturated and are therefore worth considering.

A thorough location analysis also takes criteria such as rent, the current employment situation, wages and many other factors into account. How you prioritise each individual factor is crucial when selecting an economically viable location.

What costs can I expect to incur when establishing an independent nursing service?

Before you establish your ambulatory nursing service, you should draw up a detailed business plan that calculates all costs to be paid. You should take the following points into consideration when drawing up your financial plan, among others:

• Costs of establishing the business
• Equipment like a vehicle fleet, medical equipment, workwear, office equipment, etc.
• Costs of leasing or renting business premises
• Personnel costs
• Insurance for your company, personnel, business premises, etc.
• Taxes
• IT costs
• Marketing and advertising
• Professional training and development
• Reserves to ensure the business’s financial security

Make sure to take both startup and ongoing operating costs into account, such as the costs for company vehicles.

Get comprehensive insurance

When it comes to insurance in particular, you should seek out thorough counsel to be sure that all aspects of your business are covered. Accident insurance, social insurance and professional liability insurance should be taken out in addition to commercial insurance. Hire a consultant before opening an ambulatory nursing service to ensure you’ll be well prepared for any cases of injury, financial damages or property damages.

Anticipate costs

Be sure to remember when drawing up finance plans that new companies often become profitable over time. You should have enough capital available to cover the expenses of the first few months while you focus on customer acquisition and marketing.
Your business plan should also take eventualities such as personnel shortages or vehicle damage into account.

Who do I need to employ?

Depending on which federal state your ambulatory nursing service operates in, there is a minimum number of additional healthcare professionals that you must employ. If you don’t personally oversee your service’s patient care management, you are required to employ at least one healthcare professional as a patient care manager and ensure that the position is covered during holidays and in case of sick leave so that your patients receive continuous care.

The personnel you employ are vital to the success of your ambulatory nursing service. Both you and your staff should possess the professional as well as interpersonal skills necessary to guarantee your patients’ well-being.

What expertise do I need to start an ambulatory nursing service?

Business know-how

Like entrepreneurs in any other industry, you’ll need business skills to start your ambulatory nursing service. The market for nursing care – both private and statutory – is highly competitive across Germany. We therefore highly recommend undergoing training in marketing and customer acquisition.

As the owner of a nursing care service, you are automatically categorised as an employer. You should, therefore, be knowledgeable in areas such as human resources management and leadership to get off to a successful start in business. There are also plenty of subject-specific training and development courses for healthcare professionals.
Industry-specific knowledge.

The structure of your work processes will play a key role in your business’s success. The more defined and closely monitored your operations are, the easier it will be to guarantee consistently high levels of service quality for your patients.

If you give your processes and documentation procedures a clear structure, you’ll be able to ensure the continuity of your services.

As the private nursing care sector is heavily regulated, you should consider subscribing to industry newsletters and magazines and keeping in contact with the BPA to stay current. By doing so, you can integrate changes in legislation or MDK regulations into your business model as quickly as possible.