Age-related macular degeneration (AMD) causes deterioration of the macula, the part of the eye that provides sharp, clear, straight-ahead vision. As many as 11 million people in the United States have some form of AMD, and that number is expected to increase to nearly 22 million by 2050, according to the BrightFocus Foundation, a nonprofit that supports research to end AMD, glaucoma and Alzheimer’s disease.
AMD can be passed from generation to generation, according to Dr. Steve Charles, a clinical professor of ophthalmology at the University of Tennessee and founder of the Charles Retina Institute.
“If you are the sweet daughter that brings her 85-year-old (mother) to my office for macular degeneration treatment, you need to get looked at,” Charles says, adding that there are nine genes responsible for the condition.
It’s not uncommon for those with macular degeneration to notice blurring of their central vision early on or to have difficulty reading. Some may see a dark spot or distortions such as straight lines that seem wavy, says Dr. David Boyer, a clinical professor of ophthalmology at the University of Southern California’s Keck School of Medicine in Los Angeles. To give an idea of what it’s like to have AMD, this video made available by the National Eye Institute shows how a grocery trip may appear.
Also, a person with AMD might experience contrast sensitivity, with difficulty distinguishing, for example, dark gray letters on a light gray background. “I have patients who come in who are 20/20 who tell me they can’t drive at night,” Boyer says.
Over time, some people may have difficulty recognizing faces. Eventually, without intervention, those with severe AMD may lose their central vision entirely, although they may still be able to see peripherally.
Possible Preventative Measures
Fortunately, genetics don’t tell the whole story. Environment also plays a role. For example, smoking increases your risk of getting macular degeneration almost sevenfold, while a healthy diet and regular exercise can help reduce this risk, Boyer says.
Eating fruits and green, leafy vegetables that have high levels of antioxidant vitamins — such as kale, spinach, broccoli and squash — may help to reduce the risk for AMD.
Boyer says research has shown that vitamins, such as the “AREDS 2” formulation, which includes vitamin C, vitamin E, zinc oxide, cupic oxide, lutein and zeaxanthin, have been shown to reduce progression by 25 percent and lower visual loss by 20 percent over a five-year period.
Still, Boyer does not initially recommend these supplements for people whose eyes don’t yet show any changes. “We have to be very careful because we don’t know what high doses of any of these (vitamins) over a 30-year period will do,” he says. “However, when patients show changes, then I would recommend the vitamins.”
Different Types of Macular Degeneration
There are two forms of AMD — wet and dry. About 90 percent of those with AMD have the dry form, and it progresses to the wet form in about 10 percent of patients, according to the American Macular Degeneration Foundation.
With dry AMD, lipid deposits called drusen are the hallmark. Drusen, found underneath the eye’s “retinal pigment epithelium,” a pigmented layer of cells next to the retina, can compromise the eye’s ability to metabolize waste products and lead to damage in the eye’s rods and cones. Rods help us see in low-light conditions; cones allow us to see color.
With wet macular degeneration, abnormal blood vessels leak blood and fluid into the macula causing blurred vision or blind spots. It’s possible for patients to have both dry and wet AMD.
“You can start with dry and it converts to wet,” Boyer says, adding that one eye may develop wet AMD while the other remains at the dry stage. “In those situations, the risk of developing wet AMD in the other eye is about 12 percent a year,” he says.
A 'Miracle' Treatment for Wet AMD
The most common treatment for wet AMD is anti-VEGF therapy. Charles explains that, “Every time nature wants to grow a blood vessel, it uses a molecule in the eye called VEGF (vascular endothelial growth factors).” Anti-VEGF medications act as a sponge to soak up VEGF in the AMD-affected area of the eye, Charles says.
You could call these medications “miracle drugs,” Charles says, because they have no ocular or systemic side effects. “Not a single patient got an allergic reaction and nobody required higher doses over time,” he says. The medications go by the names of Lucentis and Avastin, both made by Genentech and Eylea, made by Regeneron Pharmaceuticals.
Currently, Lucentis and Eylea are FDA-approved for macular degeneration treatment. Avastin was initially FDA-approved as a cancer agent, but is used by 70 percent of practitioners for treating wet AMD, Charles says. Avastin costs about $50 per injection versus about $1,850 per injection for Eylea and Lucentis. While these well-accepted treatments are covered by Medicare and other insurance, many plans will not allow patients to use anything by Avastin, Boyer notes.
Treatment with these drugs can go on indefinitely. Some of Boyer's patients are still maintaining their vision after being on the drugs for more than a decade. The sooner patients start on the treatments the better, since 70 percent of patients on these drugs are able to maintain the vision they had when they started, Boyer says.
Audre Slater, 88, who has battled macular degeneration for more than 20 years, is one such patient. She’s been able to maintain the vision in one of her eyes since Boyer started her on anti-VEGF medication. Unfortunately, prior to going to Boyer for treatment, she had already lost vision in her other eye.
For Slater, the effects of the anti-VEGF drugs have been profound for the vision in her working eye. “Since I went to Dr. Boyer with this forever ago, I just get a shot in my eye every two and a half months … and he keeps me seeing perfectly,” she says, adding that she’s still able to read.
Emerging Treatments for Dry AMD
Unfortunately, for dry macular degeneration, there are no such treatments. Many studies have proven unfruitful for the most part, Boyer says.
One treatment that has shown some promise in FDA trials involves injections of a drug called APL-2, made by Apellis Pharmaceuticals, to slow “geographic atrophy.” In this type of dry AMD, cells in the retina waste away and die.
Currently in research trials, APL-2 has shown to reduce the rate of geographic atrophy by 20 percent. But the tradeoff was an 8 percent increase in the wet form of the condition, Charles observes, adding that while this is not a magic bullet, it may make sense to try it together with an anti-VEGF agent.
The use of stem cells is also being looked at for dry AMD. But it is strictly in the experimental stage and Charles stresses the need for caution. Scam stem cell clinics have popped up in places likes Florida and Mexico. Charles says they use the wrong type of cells, obtained through liposuction, that couldn’t possibly help and could even cause blindness.
Treatments continue to evolve. With any form of macular degeneration, those affected should visit a qualified practitioner as soon as possible to learn how they can ultimately best preserve their vision.


The Basics About Age-Related Macular Degeneration

Maxine Lipner

Social distancing and stay-at-home orders due to the coronavirus (COVID-19) crisis have led many health care providers to conduct visits with patients through telemedicine — providing medical and mental health care using the internet and telecommunications technology. People who never wanted to try telemedicine before are suddenly getting a crash course in how it works.
Even those who may not have grown up with computers, tablets or smartphones are acclimating and giving this form of health care a try, says Dr. Michelle Lin, associate director of telehealth for the Mt. Sinai Health System in New York City.
“We have seen a dramatic increase in the proportion of patients using our telehealth services here at Mt. Sinai who are older and who have some chronic medical conditions,” Lin says.
More People Embracing the Technology
Before the crisis began, only about 10% of U.S. residents had used telemedicine, according to a July 2019 J.D. Power survey. Now, volume, at least at Mt. Sinai’s site, is 10 times higher than usual, she says.
"We have seen a dramatic increase in the proportion of patients using our telehealth services here at Mt. Sinai who are older and who have some chronic medical conditions."
While some Mt. Sinai patients using telehealth have COVID-19-type symptoms and are seeking guidance on whether they need go to the hospital, others are using it to avoid coming in contact with anyone who might be contagious. “We know the risk to older folks is higher when they do get infected, so I think it’s beneficial to both patients and providers to keep patients at home who are well enough,” Lin says.


Our Commitment to Covering the Coronavirus


We are committed to reliable reporting on the risks of the coronavirus and steps you can take to benefit you, your loved ones and others in your community. Read Next Avenue's Coronavirus Coverage.


Medicare Allows More People 65+ to Use Telehealth
What’s more, the Centers for Medicare & Medicaid Services (CMS) has recognized the current need and recently changed Medicare telemedicine rules to accommodate patients, says Dr. Sirisha Mohan, clinical assistant professor at the Keck School of Medicine at the University of Southern California (USC). Mohan also is the department lead for telehealth at USC.
“Prior to all of this COVID pandemic, telemedicine was limited in terms of use because Medicare had more stringent guidelines on when telemedicine could be used for patients older than 65,” Mohan says. Medicare limited its use to rural patients, and they had to go to designated clinics or hospitals for their visits.
But, as of March 17, 2020, the rules changed, allowing more Medicare beneficiaries to receive medical advice from their doctors without going to a clinic or hospital. "CMS is expanding this benefit on a temporary and emergency basis," according to the agency's announcement.
Medicare announced these specifics about its telemedicine changes:
Medicare co-pays and deductibles still apply to telemedicine visits, but health care providers will be allowed to waive or reduce these costs.Clinicians must use an interactive, real-time audio and video telecommunications system. Medicare will waive penalties for potential violations of federal health care privacy laws if clinicians make good-faith efforts to serve patients.Hospitals and a range of health care providers can use telemedicine, including doctors, nurse practitioners, mental health professionals and nutrition professionals.Nursing home residents also can consult health care professionals via telemedicine.Many health care providers also offer “e-visits,” in which patients use a secured part of their health care provider’s website to fill in a questionnaire about their symptoms. Then, a doctor or other provider gets back to them with a treatment plan and, if needed, a prescription. E-visits work for non-serious medical issues in which in-person tests are unnecessary.
Novices Give Telemedicine a Try
As someone who is at increased risk for COVID-19, Barton Colin, 69, is one USC patient who has embraced the technology. With several chronic conditions, including chronic obstructive pulmonary disease (COPD) and chronic pain from a spinal issue, Colin was relieved that he could skip the difficult and risky trip to the doctor’s office.
“You watch on TV and there are six different categories (for COVID-19 risk) — five of them have me pinned right on as very vulnerable,” Colin says.
So, when his COPD lung condition flared up and he found himself gasping for breath, he decided to try telemedicine instead of risking an office visit. Making the virtual visit happen was as simple as clicking a link he received in an email from his clinic. Using his smartphone, he was able to see a tiny picture of the doctor on his screen and the practitioner was able to see him as well. It was a different doctor than he usually sees because his usual practitioner was off that day.
After looking over Colin’s chart, the doctor was up to speed and ready to help, prescribing Colin antibiotics. The medication helped at first, but two weeks later, he needed to reach out once more and was able to speak with the same doctor, who prescribed some additional medication.
Colin found the whole process very easy. “It was like calling up a friend and talking to him,” he says.
Likewise, Paul Fraser, 37, another patient at USC, found using telemedicine pretty straightforward. He opted to give the virtual approach a try, rather than the in-person follow-up visit he would have needed for the undiagnosed intestinal issues he was having.
"It was like calling up a friend and talking to him."
With COVID-19 on the rise, and serious diagnoses already ruled out, Fraser felt it would be easier to use telemedicine for his follow-up exam. The technology was simple to use on his laptop, he says. After clicking the link that was emailed to him, he first spoke with a customer service rep, who then directed him into a virtual waiting room. After a couple of minutes, Fraser's primary-care doctor showed up on the screen and the follow-up visit began.
Lin describes using the Mt. Sinai platform as very similar to a regular doctor’s visit.
“The first time you register, you have to enter a little bit more information to help us get to know you,” she says, adding that this includes standard information, such as your date of birth. Once patients input this information, they then fill out a quick questionnaire and enter a virtual waiting room, which alerts the doctors that they are there. “Then we open our video and you open yours,” Lin says, adding that the visit proceeds much as it would in the doctor’s office.
Telemedicine for Mental Health
Many people are now using telemedicine for mental health as well as physical health, moving forward with psychiatric follow-up appointments or psychotherapy sessions.
These days, Lauren Saletan, a licensed clinical social worker and psychotherapist in Nyack, N.Y., is conducting most of her therapy sessions virtually.
“I would say eighty percent or maybe eighty five percent have moved to online,” she says.
Saletan had to persuade several clients who had never used the video-chat app she uses before. Taking part in such a session just requires clicking on a link. Saletan encourages her clients to give it try, assuring them that it will be a lot like an office visit, and she’s found her clients agree. “Everyone has said, ‘Wow, it’s really like we’re together,’” she says.
In fact, she says it’s easy to forget it’s not an actual office visit. “I have been a therapist for over twenty-seven years and when we’re engaged and we know each other, it’s like we’re in the office,” she says. “As long as we’re connecting, it doesn’t matter whether it’s over a screen or in the office, is what I have found.”
Even after the pandemic subsides, Saletan believes some of her clients may wish to continue with telemedicine. “Some people may prefer it moving forward, because they’re working and life is busy. So, that will be a wait-and-see,” she says.


You Can Still See a Doctor, Through Telemedicine

It can be the bane of existence for those at midlife: the need to have reading glasses at the ready, particularly in darkened conditions like a dimly lit restaurant with a menu that lists dishes in type too small to decipher.
“Usually at around (age) 43 to 45, patients start noticing that they need to hold things farther out and they need more light,” says Dr. Daniel Durrie, clinical professor of ophthalmology at the University of Kansas Medical Center, and founder of Durrie Vision in Overland Park, Kan.
At the heart of this universal condition, known as presbyopia, is the lens in the eye. Our lenses naturally stiffen as we age, making it more difficult for them to change shape to focus on things close up. The stiffening is caused by “disulfide bonds” building up in the lens.
While the lens is still crystal clear at this point, the initial problem is getting it to focus for reading, Durrie says. This is known as stage 1 of dysfunctional lens syndrome. During stage 2, the lens begins turning yellow and gets a little bit hazy. By stage 3, the disulfide bonds build up so much, they block the light rays and cause a cataract, Durrie says.
Fortunately, for those in the early stages of presbyopia, there are a variety of options that can help minimize or even do away with the need for reading glasses. They include: corneal inlay devices; refractive surgery in one eye to help with reading and eye drop options now being tested in clinical trials that promise to temporarily enhance close-up work.
Pinhole Device Sharpens Vision
For patients with good distance vision who are frustrated by the idea of dependence on glasses for reading, a corneal inlay device in one eye may help provide near vision. Likewise, for those whose distance vision isn’t on par, it’s also possible to have that corrected first using refractive surgery, and then receive the inlay for near vision.
Currently, there is only one Food and Drug Administration (FDA)-approved corneal inlay: the Kamra (CorneaGen) inlay. This opaque, donut-shaped device is placed in the eye in front of the pupil, narrowing the pupil and producing a pinhole effect.
“What the Kamra does is it changes the optics of the cornea so that it’s like narrowing down the F-stop (aperature) in a camera,” Durrie says. “Any photographer would say, ‘Oh, that increases your depth-of-focus, so it gives you a better range.’”
The Kamra inlay is primarily for those whose lenses are just beginning to stiffen but are still clear, making it basically an option for people age 45 to 55. If the lens is already getting hazy, the Kamra inlay will only cut down further on the light, Durrie warned.
The Kamra inlay is placed in just one eye at a LASIK (laser-assisted in situ keratomileusis) surgery center in a 10- to 15-minute outpatient procedure. Unfortunately, neither Medicare nor private insurance cover this or other presbyopia procedures. Getting the inlay implanted in the eye costs around $2,000.
The 'Blended Vision' Technique
Another option for some patients may be “blended vision,” in which one eye is tweaked to allow for reading while the other is corrected for distance. In true monovision, one eye is fully corrected to see best for things near and the other completely for distance. With blended vision, there is less difference between the eyes, so the two prescriptions meld comfortably together. Durrie likens it to stereo music.
“In stereo music, everybody knows that the speakers are not playing the same song, but it sounds great,” he says.
The blended-vision correction, also known as mini-monovision, can be made with a laser procedure such as LASIK or PRK (photorefractive keratectomy), or with a technique known as SMILE (small incision lenticule extraction), says Dr. Richard L. Lindstrom, adjunct professor emeritus at the University of Minnesota in Minneapolis.
With LASIK and PRK, an excimer laser is used to reshape the cornea to let people read more easily. With SMILE, a femtosecond laser cuts a sliver of tissue beneath the surface, which is then removed through a tiny incision.
In some cases, this blended vision in which one eye is left slightly nearsighted, can provide patients with enough reading vision to make them happy, Lindstrom says. In other cases, however, this procedure may just be the first stage before implanting the Kamra inlay.
Lindstrom finds that the blended vision approach may work for patients up to about age 60. Even after this, it may be enough to give people good intermediate and distance vision and let them see their computer screen or their car’s dashboard.
Blended vision also is not covered by insurance. When done with LASIK, this runs about $1,950 per eye.
Eye Drops Being Tested
One non-surgical approach being tested in clinical trials is eye drops. There are two types of drops currently winding through the FDA regulatory process. Their availability is still several years out, and it's too soon to tell what they will cost, but these could be a great option for people who want a less invasive solution.
“The first set of drops just make your pupils small,” Lindstrom says, adding that the drops employ the same principle of pinhole optics as the Kamra inlay to increase the patient’s depth of focus. The idea is to put the drops in both eyes to allow for better reading during a four-to-eight-hour period, he says.
Another type of eye drop aims to counteract the process that stiffens the lens, allowing it to be more flexible again. One clinical trial including 75 patients showed measurable improvement in near vision with this type of eye drop. Lindstrom expects those results could translate into about a five-year reduction in age for the eyes. So, if someone is 50, it will restore the eyes back to the way they were at, say, 45. However, it would actually take about 400 patients to confirm this, he noted.
“That would be very attractive; it would be like a fountain of youth for your eyes,” he says. Ultimately, in the end, all of these options can functionally help to turn back time.


If You Hate Reading Glasses, Here Are Other Options

(This article appeared previously on Kaiser Health News.)
During Anne Soloviev’s semiannual visit to Braun Dermatology & Skin Cancer Center in Washington, D.C., in January, the physician assistant diagnosed fungus in two of her toenails. Soloviev is vigilant about getting skin checks, since she is at heightened risk for skin cancer, but she hadn’t complained about her toenails or even noticed a problem.
The assistant noted some unusual discoloration where the nail meets the skin. “They took a toenail clipping and said, yeah, you have a fungus,” Soloviev, 77, recalled.
So the physician assistant called a prescription into a specialty pharmacy with mail-order services (My Express Care Pharmacy), which would send medication to Soloviev’s Capitol Hill home.
It seemed like an easy fix to an inconsequential health issue. “I did not ask how much it cost — it never crossed my mind, ever,” said Soloviev, a former French teacher, who still works part-time.
Then the bill came: $1,496.09 for Kerydin, a topical medication originally produced by Anacor Pharmaceuticals and now a product of Sandoz, a Novartis division.
An Unwelcome Surprise
Soloviev is covered by Medicare, Parts A and B, and has supplemental insurance through her late husband’s government health benefits that covers prescription drugs. She also has a health reimbursement account (HRA), which contains almost $1,500 pretax dollars each year to pay for uncovered medical expenses. She typically uses that pot of money to cover co-pays for the other medicines she takes regularly.
The initial Kerydin prescription arrived by overnight mail, and an automatic refill came a few weeks later. Soloviev began swabbing it on the two toenails, as directed, having been told it would take about 11 months to treat the fungus.
She thought little of it.
But when Soloviev went to her local CVS to pick up another medication — a statin that is usually paid for by her HRA — she discovered her HRA reserve was empty.
Unbeknownst to her, Kerydin, which it turned out costs nearly $1,500 per monthly refill, had wiped out her entire reimbursement account.
The price tag is difficult to rationalize, experts said.
“Reality check — this is $1,500 for a medicine to treat [it],” said Wendy Epstein, an associate law professor at DePaul University, who researches health care law. “That’s quite a chunk of change.”
Leslie Pott, Sandoz’s vice president of communications, explained that Kerydin is patent-protected and priced “at parity” with its one market competitor, Jublia. She also pointed out that to secure a place on an insurer’s list of approved drugs — its formulary — the drugmaker often had to offer substantial discounts to insurers and various middlemen. “We have no visibility into the extent to which these discounts are passed onto patients or payers,” she wrote in an email.
Other Options Were Available
There are many prescription treatment options for toenail fungus — both older medicines in pill form and newer topical treatments such as Kerydin, said Dr. Shari Lipner, an assistant professor at Weill Cornell Medicine and director of its nail unit. The patient in this case would have been a candidate for “quite a few” of them, she said.
Patients are likely to pay less for the pills, for which a course of treatment lasts three months, compared with the newer topical treatments, noted Lipner, adding that the pills also seem to have greater efficacy.
In its application for Food and Drug Administration approval granted in 2014, Anacor Pharmaceuticals highlighted that a yearlong treatment of Kerydin completely cured toe fungus in 6.5 percent of patients for one trial and 9.1 percent of patients in another.
Over-the-counter treatments are also available, but there’s not much data on them, Lipner said.
Cost ‘Isn’t a Factor’ for Physicians
Xavier Davis, Braun Dermatology & Skin Cancer Center’s practice manager, said a drug’s price tag simply isn’t a factor when prescribers recommend a course of treatment.
“When our providers are treating patients, we’re not treating them based on what the cost’s going to be. We look for what’s the best care for the patient,” Davis said. “If the patient calls and says that’s too expensive, then we’ll look for alternatives.”
Dr. Kavita Patel, a nonresident fellow at the Brookings Institution and a practicing physician, said this process contributes to the problem. “My sister’s a dermatologist, and she’ll do the same thing — she’ll prescribe and she doesn’t know. You’re getting at many layers of how [messed] up the system is, starting with the doctor doesn’t know.”
And patients often don’t see the actual price. Or they see it too late, when they’re at the pharmacy counter picking up medicines they have been told they need or in a roundabout way discover unexpected payouts.
HRA Account Drained
In January, Soloviev’s insurance plan was billed the full price of Kerydin. Of that, $1,439.57 came from her HRA. The difference, $56.52, was covered by a patient-assistance program from the drug manufacturer, explained Jonathan Lee, a pharmacist for My Express Care.
In February, when Soloviev’s prescription was refilled, her plan was again billed the full drug price. But she didn’t know about that either. A manufacturer coupon was applied to cover what remained of her insurer’s $2,000 annual deductible and the $60 co-pay. Her insurance then kicked in to pay the difference.
Such patient-assistance programs and coupons are meant to insulate patients from cost sharing, so they don’t feel a pinch from a drug’s price. But in this case, the drugmaker’s patient-assistance program apparently took effect only once Soloviev’s HRA has been wiped out, allowing the manufacturer to maximize revenue from both patient and insurer.
Epstein said it took her “15 minutes to figure out what was going on” here. And, unlike the average patient, she studies this issue for a living.
Lee, the pharmacist, said even he didn’t realize that money could be withdrawn directly from a patient’s HRA without her knowledge, and he’s been in the business for the better part of a decade.
No Warning for Patients
None of that is consolation for Soloviev, who said: “I just find it is outrageous for a fungal medicine to cost $1,400, to be prescribed for 11 months, and for neither the PA [physician assistant] nor the pharmacy to warn you,” Soloviev said.
Resolution: Though Soloviev has told My Express Care not to renew the prescription, her HRA is depleted. For the rest of the year, she’ll have to pay out-of-pocket costs for any other medications, an expense she hadn’t planned on.
The Takeaway: For even the most informed of patients, getting a new prescription can mean walking through a financial minefield. And Soloviev hit a number of booby traps.
Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it’s beneficial.
Patients should play defense and ask their physicians about the cost of every new prescription. They should ask again at the pharmacy — even if that means calling a mail-order pharmacy. Because costs can vary depending on each patient’s coverage, they may need to contact their insurance carrier or the pharmacy benefit manager that handles their medicine claims.
And if the cost is extremely high, they should ask their doctor about generic or over-the-counter alternatives.
“This is an important component of the decision a patient’s going to make,” Epstein said. “If it’s toenail fungus and not life-or-death, it strikes me … an individual might want to have relevant data.”


For Toenail Fungus, A $1,500 Prescription

Shefali Luthra

Restoring a forest isn't usually a project people take on when they're in their 60s. But when Southern Oregon's natural beauty hooked San Francisco urbanites Fred Gebhart and Maxine Cass they decided to abandon city life and take on the challenge.
Fred Gebhart and Maxine CassIn 2010, the couple inherited 20 mostly wooded acres from Gebhart's mother. Knowing that the house on the property needed repairs, they went to inspect. When the sun woke them the next morning, it pointed them to a new life direction.
"We groggily got up and looked outside," said Gebhart. "It was early June and we saw a beautiful green meadow. Wildflowers. Oaks were freshly in leaf. Everything was bright and shiny. The sun was coming through a pair of table rocks with a snow-capped Cascade mountain in the background. Our mouths just dropped."
Instantly, they both thought of relocating there. "Can we do this?" he recalled saying. "How would we do this?"
Taking Stock and Making the Move
The couple took stock of their resources and what they'd need to be able to live on the property. With an existing DSL line, Gebhart could continue his work as a medical writer remotely. Cass had already retired from travel writing and photography.
"We couldn't get to some parts of the forest ... We had to bushwhack to get into the back woods."
For both, their age was an obstacle to changing health insurance plans. But the Affordable Care Act opened that door, allowing them to set early 2014 as their move date.
In the meantime, they planned to travel to their land every few weeks and learn all they could about home repair and the plants, animals and weather there.
As they got to know the property, they found they owned a 20-acre tangle of trees, blackberry brambles, 12 to 14 feet tall Scotch Broom shrubs and poison oak running up 100-foot trees.
"We couldn't get to some parts of the forest," said Cass. "You couldn't see what was there. You could sort of see your way through overgrown logging roads and paths previous owners had built but we had to bushwhack to get into the back woods."
Eventually, they realized they had not just one but two forests, one hardwood and the other mixed conifer.
The buildings also showed the effects of delayed maintenance. More than they knew. And more than they knew how to fix. As urban renters for 33 years, "we didn't have a clue," Gebhart said, smiling at the memory. "We were so unprepared we didn't even know what questions to ask."
An Expensive Education
They discovered the house needed a new roof, electrical system and paint inside and out. The septic system was clogged, two wells and a cistern pump had to be replaced, and three outbuildings were not salvageable. Gebhart came home one day and told Cass, "I have two words for you. Wells and septic."
"We have wells?" Cass asked.
"Yes, but nobody knows if it's one, two or three."
"What's a septic?" she asked.
Fond Memories but No Skills
Having lived his early childhood in the Ozarks, Gebhart said he had "fond memories of outhouses" but no knowledge of plumbing. The couple's two years in the Peace Corps in Senegal in the late 1970s offered no help either. They had taught English and French.
"In cities, whether water, sewer and electricity worked or not, it wasn't our problem to repair it," said Gebhart. "We discovered in the country there's no one to call. We got to fix all of that stuff."
"If not for Oregon State [University] Extension and Google we'd have been lost," said Cass. "We sucked up information and went from there."
"Family Forest" Stewardship
Cass and Gebhart are two of the nearly 10 million "family forest" owners in the U.S. According to the Family Forest Research Center, a family forest can be as little as one acre with at least 10% trees owned by an individual, family or unincorporated group.
In fact, family forests make up the largest percentage of American forest land. In total, they cover more acreage than all of the national forests combined.
Brett J. Butler, co-director of the Family Forest Research Center and author of "America's Family Forest Owners," says these individual owners' collective decisions will influence the fate of America's forest ecosystem.
Even so, most family forest owners have no stewardship plan nor have they consulted professional forest managers for advice. Some may not even know help is available.
Asking Experts for Advice
For Gebhart and Cass, assistance came from the Oregon Forestry Department and the local soil and water district. Working with these entities, they developed a 10-year forest stewardship plan.
With an approved, written plan they qualified for a multi-year cost-share grant as well as direct contributions. For example, a forestry crew brought a massive chipper and spent two days cleaning up dead trees, returning the wood's nutrients to the forest rather than hauling them away.
Most of the work, though, is DIY. Propagating and planting native shrubs, caging new plants to protect them from grazing deer, seeding native wildflowers and tree-thinning, limbing and pruning, Cass and Gebhart share the load.
To avoid using fire or chemicals to control weeds, they cut and hand-pull all unwanted plants. "We're legendary weed-pullers," said Cass, concluding a story about clearing an acre of weeds by hand.
A Photographer's Paradise
"It was six years before we could even see the whole twenty acres," said Gebhart. Now you can see all way through to the edges. Flowers grow in the forest where there were none. Trees are trimmed with six to eight feet of clearance for walking under.
"The wildlife here is striking."
Their biggest surprise is the variety of trees, at least 11 where three or four was expected. "People don't believe it," said Cass. But visitors have seen it for themselves. While Gebhart and Cass participate in virtual classes and take field trips to other restoration projects, they also host groups for what they call "walkabouts."
For Cass, their land is a photographer's paradise. "The wildlife here is striking," she said. "We don't have any window coverings − not something you can do in the city. We pay attention to what's going on outside, whether it's animals, what the trees are doing, what the weather's doing."
One day a herd of Roosevelt elk appeared outside her bedroom window. Photographers know you don't shoot through glass, but you don't step in front of elk, either. Cass spent an hour and a half watching and photographing.
With delight at the unexpected, she saw skimmer dragonflies land on their truck bed and battle for territory. "I got great action shots of them coming at each other," she said.
Perspective and Attitude
Gebhart marvels at his new perspective on the natural environment. In an urban setting, he said, you might see birds, rats or squirrels, but few other animals, and their behavior is influenced by "human rhythms."
"In rural areas, it's reversed," he said. There's a "rich variety" of wildlife and "it's not our space. We're much more co-inhabitants. It's a very different outlook to realize we need to fit in with their world instead of ordering it specifically for what we need."  
Not everyone shares the couple's attitude about living in such a remote area. Some think it would be "inconvenient," "daunting" or "overwhelming," said Cass. "I tell people it's an adventure. It's a big pain sometimes to come out in all weather and do what we're doing."
A Decade-Long Adventure
"But it's also a privilege," she added. "I get to see things others don't and photograph and absorb it. Seeing a big leaf maple for the first time, it's whoa! Like a five-year-old kid. It puts you in a positive state of mind and helps you face challenges. You're not pushed down by it. After ten years, it's still an adventure."
Where some see boredom, Gebhart and Cass see opportunity. "Everything is so new, there's always something to learn or discover or figure out," said Gebhart.
Cass has become a Master Gardener, and both completed Master Food Preserver, Land Stewards and Master Woodland Managers programs and the Citizens Fire Academy — all through OSU Extension.
"Who has time to be bored?" Gebhart said. "We've been learning a whole new way of life."


Quitting the City to Restore a Forest

Christina Leimer

Liz Kozlowski and her staff at Brookdale Senior Living’s Westlake Village, outside of Cleveland, knew that resident Ed Petrigac and his wife Yvonne had started an auto parts business. But it wasn’t until they read his life story that they realized he also had a love of cars. That knowledge helped the staff provide better, more patient-centered care for Petrigac, a Korean War veteran who lived in the facility’s memory-care unit.
Ed PetrigacAnd, based on a recent independent study conducted through a grant for my firm, MemoryWell, familiarizing professional caregivers with residents’ life stories can be impactful for the people with dementia in long-term care — and their families.
Considering that the median cost of a private room in a nursing home is now roughly $100,000 a year, according to Genworth Financial, person-centered care has become essential to ensure your loved one gets the best long-term care for the money. Families want to be assured their loved ones in memory-care communities are known and treated like the person they know and love.
A Trip to the National Car Show
In Petrigac’s case, Brookdale’s staff read the story of his life that had been provided for them digitally by a professional writer. In it, they learned that Petrigac and his son, Mark, had spent three years fixing up a 1965 GTO when Mark was in high school. The revelation led to a trip with Westlake staffers to the National Car Show in Cleveland, followed by pizza — an enjoyable outing for Petrigac, who by that point spent most of his time in Westlake's memory care wing.
In surveys administered three and six months after the stories were written and shared, 83% and 90% of care workers respectively reported the life stories benefited them in their work.
“He had a great day,” recalls Kozlowski, Clare Bridge programs manager at Westlake Village, which piloted a life story telling platform last year as part of a grant from the International Women’s Media Foundation, funded by Howard Buffett for women journalists doing innovative work. In the study, writers turned their news-gathering talents on Westlake’s residents to help staff more readily know their residents.
“We learned about certain quirks or things people really enjoyed,” Kozlowski says.
The staff assumed one prim-and-proper resident had been exaggerating when she described being a pilot previously. They were surprised to read in her story that she really had been one, for many years.
What the Study of Residents With Dementia Revealed
The study offered preliminary substantiation that a digitally shared narrative approach can assist in providing person-centered care for people with dementia, replacing handwritten questionnaires that are sometimes illegible and can be hard to access by staff.
Person-centered care was developed in the late 1980s by U.K. social psychologist Tom Kitwood and has become the standard of care for people with dementia. The Alzheimer's Association endorsed it as the foundation of its 2018 Dementia Care Practice Recommendations. Until recently, little research had been done in the U.S about the usefulness of life story telling for caregiving. But U.K. and Canadian studies have shown that it builds empathy for paid caregivers and family caregivers and can also help reduce depression and improve quality of life.
In the Westlake study, about half of the facility’s residents (16 people) had their stories told by MemoryWell. Then, the Gilster Group, an independent research group in Ohio, studied the impact of those stories on many of the 25 front-line staff workers over six months.
In surveys administered three and six months after the stories were written and shared, 83% and 90% of care workers respectively reported the life stories benefited them in their work.
The researchers found that, over the course of the study, paid caregivers increasingly accessed the digital platform hosting the stories and allowing families to add photos, music and movies and staff to search them. The proportion of staff who reported referring to the stories “frequently” jumped from 9% to 31% between three and six months and those who reported referring to the stories “periodically” increased from 18% to 38%.
The Key for Caregivers: Getting to Know You
Maxine H. and her nieceFeedback from the care staff also showed the appeal of a life story telling platform that lets them add new details over time. So, for example, being able to update the residents’ changing food preferences such as from chocolate ice cream to vanilla. “People change and you need to know who they are now,” one West Lake caregiver told researchers.
Getting to know the details of someone’s life sometimes improved staff’s engagement with the person, too.
For example, the caregivers initially only knew that Maxine H. had worked for a railroad company. But they learned in her story that she also had loved spending her downtime in Cleveland’s Tower City District. So, as part of a Westlake activity that lets residents explore local towns virtually, when Maxine is present, the staff makes sure to “visit” that district.
The stories “give me a sense of comfort knowing I am providing the best personal care I can based off the resident’s needs,” one Westlake staffer told researchers.
Answering More Questions About Person-Centered Care
Can a better understanding of residents’ histories, likes and dislikes reduce the overreliance of psychotropic medications in long-term care facilities for people with dementia who become agitated or aggressive? And, can tools for understanding and relating to difficult residents help professional caregivers find more job satisfaction, so they’ll stay in their jobs longer?
To help answer these and other questions, MemoryWell has applied for a small business innovation research grant from the National Institute on Aging to conduct some of the first U.S.-based research on a much larger scale.


Getting a Parent With Dementia the Best Long-Term Care for the Money

Jay Newton-Small

In this new series, Next Avenue will follow Patricia Wynn as she embarks on becoming an entrepreneur with her North Carolina lifestyle assistant business. Future installments will note her progress, with advice for her and for other midlife entrepreneurs.Patricia Wynn, 52, of Hillsborough, N.C., just began her business as a lifestyle assistantThe pandemic has motivated many people to reconsider their career paths. For Patricia Wynn, a single, 52-year-old in Hillsborough, N.C., it meant being open to the possibility of becoming an entrepreneur.
"My relatives encouraged me, as someone who suffers from coronary artery disease, to make a change from the pressures of managing a fast-food restaurant during a pandemic."
"I spent twenty-six years at McDonald's in Atlanta, rising up the ranks to become general manager. Then in 2015, I moved back home to Hillsborough to help care for my mother before she passed, and became a general manager at Wendy's," says Wynn.
The Wendy's job lasted five years. In April 2020, she quit and decided to pursue a path as an entrepreneur, becoming part of the growing national trend of minority entrepreneurship.
As I noted in my Next Avenue article, "The State of Minority Entrepreneurshp in America," according to the Ewing Marion Kaufman Foundation, 2020 produced a surge in the creation of Black-owned businesses; about one in 250 Black adults started a new venture during that pandemic year.
Changing Her Original Plan
In Wynn's case, "my relatives encouraged me, as someone who suffers from coronary artery disease, to make a change from the pressures of managing a fast-food restaurant during a pandemic," she says.
While reviewing her expertise — which included managing staff, being food-service certified and caring for older family members — Wynn first considered running a group home for older adults.
Wynn then began working part-time at a home health care agency to familiarize herself with what would be required to open a group home.
"While at the agency, my first client had mild dementia. He was a former professor. I would talk to him, do his laundry and cook for him. He liked soul food!" says Wynn. "Near this time, I found a person with a group home, and she suggested that I take required courses and shadow her."
But the cost of the education would have been about $13,000. "I didn't have that kind of money," Wynn recalls.
So, based on that and advice from her friend Cozze Staples, she shifted gears.
"I decided that it would be more cost effective to start a business as a lifestyle assistant — doing meal preparation, running errands, housekeeping and offering companionship for clients."
Wynn noticed that on the website Care.com, for $12.99 a month, you could create a business profile advertising the services you provide. That, she realized, would give her a chance to trumpet her lifestyle assistant skills.
Why People Hire Her as a Lifestyle Assistant
While working at the home health care agency, in February 2021, Wynn got her first response from her Care.com profile.
Wynn with client Katherine Bland, who she assists with housekeeping and cleaning It was from a local couple in their early 80s, Virginia and Dr. Redford Williams. She's co-founder of a life skills company; he's a Duke University professor of psychiatry and psychology.
"After doing a background check on me, they hired me for eight hours, every Thursday. This couple wants to stay in their home and not go into a retirement home," says Wynn. "In addition to cleaning their house, I also walk through the property to see if there are any repairs needed that I should inform their maintenance person about."
The Williamses, Wynn says, "are my biggest fans."
Wynn mentioned to the home health care agency owner that she wanted to open her own business and the owner highly recommended seeking a free mentor through SCORE – the national organization of retired business executives affiliated with the U.S. Small Business Administration.
Getting a SCORE mentor when starting a business in midlife is something Nakeisha S. Lewis, associate dean and diversity, equity and Inclusion ambassador at the Opus College of Business, University of St. Thomas in St. Paul, Minn., recommends. (EIX, the Entrepreneurship Innovation Exchange at the university's Schulze School of Entrepreneurship, is a funder of Next Avenue.)       
Wynn began having Zoom meetings with her SCORE mentor, Maxine Stern, 78, a former Duke University CPA who lives in Chapel Hill, N.C., not far from Wynn, and has been volunteering with SCORE for about 10 years.
Says Stern: "I think Patricia's management background at McDonald's and Wendy's helped her a lot. She's not afraid of collecting data. She is not hesitant about the things you need to do to build a business."
Smart Advice From Her SCORE Mentor
Wynn notes: "Ms. Stern really helped me. She was very motivational."
Stern sent Wynn notes on how to apply for an LLC — a limited liability company that would provide personal asset protection. Stern also provided advice on the requirements to become a certified nursing assistant (CNA), in case Wynn wanted to work in a group home.
"We also talked about the rate I should charge as a lifestyle assistant," says Wynn. They decided that charging $20 an hour made the most sense, based on eventually working a 40- to 50-hour week.
"She wasn't afraid of the business, but there were things she didn't know."
"That was almost double what I made working part-time for the agency," says Wynn.
At each of their meetings, Wynn made sure she'd accomplished what the two of them had discussed the month before.
Stern said some would-be entrepreneurs come to SCORE with an idea, but then don't continue with the mentoring program when they find out all that's required to start a new venture.
"It can be overwhelming for some people," she says. But not for Wynn.
"She wasn't afraid of the business, but there were things she didn't know," Stern says. "She had to learn how to have her own business. It's a really different concept from being an employee."
Describing Wynn as a "smart, capable person," Stern said she and Wynn always discussed the "why" behind the monthly goals they agreed on.
Launching Patricia Services, LLC
In April 2021, Wynn officially launched Patricia Services, LLC, with an initial investment of less than $5,000 in her small stash of savings. "The business has to pay for itself," says Wynn.
She has three first-year goals for the business: "First, my ultimate goal is to get as much information, and more knowledgeable, about caregiving as possible," she says. That includes finding, and taking, free classes about caregiving and on how to speak to people suffering from dementia as well as getting caregiving certifications.
SCORE mentor Maxine Stern
"Second, I'd like to be able to add two more staff members. Third, I want to increase my advertising by creating flyers that I can distribute among contacts in social services who specialize in elderly or disabled clients of various ages," says Wynn.
She began developing her client list while working part-time at the home health care agency until September 2021, when she quit that job to devote all her energy into her lifestyle assistant business.
Today, Wynn has a diverse client base of six people, ranging from older adults to busy college professors and other professionals who are Gen Xers and millennials. She also does some weekend cleaning at a local bed and breakfast.
"With all of my clients," she notes, "I set it up so they can hire me for a minimum of four hours per week. That can be spread out through one, two or more days."
One client is Katherine Bland, a Duke University professor who has hired Wynn to help with housekeeping and cleaning. Another, Jaya Kumar, even sends Wynn weekly meal recipes to prepare for her family, since her time is limited while also completing a doctorate. 
 "The younger professional people need you because they work all the time," says Wynn. "The senior citizens need assistance to remain independent with their everyday activities."
Her Plan for Growing the Business
Wynn now has her LLC designation, a website and a profile on Care.com. She recently decided to add decals on her car advertising Patricia Services, LLC.
In the spring, she qualified for a federal government PPP (Paycheck Protection Program) loan of $4,375. She used it to pay her nephew and brother when they occasionally did heavy furniture hauling for her business.
So far, Wynn is plowing most of her earnings from Patricia Services back into the business — to pay for things like its mobile phone bills, gasoline charges, the Care.com profile and the website.
"Looking toward 2022, I would like to add another staff member," Wynn says. "But I have to grow slowly because if that person is out sick, I'm the one that would have to service their clients."
And in the category of "long-term goals," Wynn is investigating expanding her client base by becoming a vendor with the North Carolina Client Assistance program, which helps state residents with disabilities live more independently.
But right now, she says — with a nod to the McDonald's slogan — "I'm loving it."
She adds: "I'm thrilled to not have to go back to managing Wendy's. I'm proud to be starting a new chapter in my life. I've helped make Wendy's and McDonald's owner operations millions over the years, so I'm looking at using the skills I developed there and making something of my own and working at my own pace."
This article is part of America's Entrepreneurs, a Next Avenue initiative made possible by the Richard M. Schulze Family Foundation and EIX, the Entrepreneur Innovation Exchange.

Our New Series: The First Year in the Life of a 50+ Entrepreneur

Leslie Hunter-Gadsden

Performance artist and comedian Kristina Wong planned to go on tour in March 2020. For reasons we're all too familiar with, she didn't, leading to her feeling depressed and unsettled, both by the loss of her occupation and the global pandemic. 
"The Auntie Sewing Squad Guide to Mask Making, Radical Care and Racial Justice"Wong sews pieces for her shows, so at the beginning of the pandemic, when trying to think of a way to help, she hit upon making masks. Wong felt getting these to people in great need — farm workers, members of Indigenous communities, and people in prison — was the most patriotic thing she could do.
"I'm never going to be in the position where people are like, 'Oh, if I don't have some smart social commentary, I'm going to die,'" Wong said. "That never happens. I had actual people who were saving other people's lives like firefighters and nurses who were running out of masks."
The Auntie Sewing Squad sent out more than 300,000 masks all across the United States. 
As requests for two masks turned into four, then turned into hundreds, Wong realized she couldn't possibly keep up herself, so she started an informal Facebook group, asking for people who knew how to sew (or were willing to learn) and who wanted to help make masks for people who needed them.
Like requests for masks, the number of volunteers grew and grew until there were hundreds of people around the country, many of them Asian American women, calling themselves the Auntie Sewing Squad, with Wong using "Sweatshop Overlord" as her title. (In Asian culture, the word "auntie" is used as a sign of respect and affection.) 
The Auntie Sewing Squad sent out more than 300,000 masks all across the United States.
Their Story Became a Book 
Now the group has put out a book, "The Auntie Sewing Squad Guide to Mask Making, Radical Care, and Racial Justice", with essays, drawings, photos, and patterns for masks, along with recipes for things like vegan kimchee, chocolate shortbread cookies, and a nourishing salve.
Edited by three California professors, Mai-Linh K. Hong, Chrissy Yee Lau, and Preeti Sharma, the topics include sewing masks for fun and no profit, ancestors, and sewing as care work. Wong, historian and writer Rebecca Solnit, and dozens of other Aunties contributed essays.
The book has received praise from a diverse group, including author Maxine Hong Kingston, comedian Margaret Cho and New Yorker writer Jia Tolentino.
The problem they faced, Wong says, along with the scarcity of materials to make masks, was how to get the masks to their destinations in places like rural areas or indigenous communities. This led to a system of "Super Aunties" making sure things would get to where they needed to go.
Wong, accustomed to writing grants from her years in theater, decided they needed some simple markers to track their progress, such as how many masks people needed, who they should be sent to or who would pick them up, and the date they were needed. 
"We decided to just sort of lay out some conditions; [we wanted] people to stop for a second and name their needs instead of just passing their panic onto us," Wong said. "You have to set up a structure or everyone will feel helpless; it's just like people are yelling at me, 'Homeless people need masks!' That's not going to help."
The book came about, Wong says, because some academics in the group were interested in how the Auntie Sewing Squad fit into histories of immigration and sewing. 
Interviews on Social Change and Asian American Women
One of the editors, Lau, didn't really sew herself before joining, but her grandmother worked for 30 years at a garment factory in Los Angeles' Chinatown. A history professor at California State University, Monterey Bay, Lau did an oral history project about the Squad, and more than 100 of her students interviewed dozens of Aunties, asking them about social change and Asian American women.
Chrissy Yee Lau"They were in the driver's seat, determining the agenda and what [questions] were asked," she said about the students. "They were in awe of the Aunties and wanted to learn from them."
Lau says she loved working on the book with Hong, a professor of literature at University of California, Merced, who specializes in Asian American studies, race, and refugees, as well as Sharma, a professor of American studies at California State University, Long Beach, focusing on labor, gender, and immigration issues.
"I'm a historian by training, and I tend to work alone," Lau said. "I loved working with Mai-Linh and Preeti and talking about how sewing is connected to racial and ethnic issues."
Wong's friend Valerie Soe, a filmmaker, professor and an OG (original) Auntie, wrote the book's introduction, "We Go Down Sewing," with the editors. 
Understanding the Auntie Phenomenon
Soe also made a short video, Radical Care: The Auntie Sewing Squad, asking the Aunties to send her clips she could put together since due to COVID she couldn't film them inside. And Soe's friend Solnit, who has previously written about mutual aid societies, introduced them to her editor at University of California Press.
"I want history to remember that we stepped up to do this. It felt like the labor of sewing is historically so invisible and undervalued." 
"The book is amazing and in the collaborative spirit of the Auntie Sewing Squad," Soe said. "It's a fun snapshot of a moment with a scholarly framing, and I hope it helps people understand Auntie phenomenon."
"I think the books are wonderful — and I would think that even if I wasn't in it," said Vibrina Coronada, a theater artist in a small North Carolina town, who wrote an essay about being a Technical Assistance Auntie, using her skills with repairing sewing machines to help others.  
"I bought a bunch of copies and sent it friends, and they really liked it. It's a nice antidote to how confined the pandemic has made life for some people," said Coronada." It's like the proverbial 'make lemonade out of lemons,' and I personally love lemonade."
Wong also created a show about the group, Kristina Wong: Sweatshop Overlord, which played off-Broadway in the fall of 2021 and ended up on several critics' Best Of lists. She says part of the impetus behind the show, like with the book, is wanting a record of what the group accomplished."I want history to remember that we stepped up to do this. It felt like the labor of sewing is historically so invisible and undervalued. This was sometimes reflected back to us in people saying something like, "Can you just sew up something like this for me?" It was like, "Uh, I know you are used to pressing two buttons and something shows up the next day, but that's not how this is going to work,'" Wong said. 
She continued, "I wanted to educate people and remind them that we did this work, and we weren't just people who quietly clutched our pearls watching our family members be beat up in the street. We also are people who did solidarity work, and who really cared."


Meet the Auntie Sewing Squad

Emily Wilson

In this series, Next Avenue will follow Patricia Wynn as she embarks on becoming an entrepreneur with her North Carolina lifestyle assistant business. Future installments will note her progress, with advice for her and for other midlife entrepreneurs.Entrepreneurs with a new startup are balancing so many things: developing and managing a new business, meeting the needs of customers and marketing to attract new ones, keeping the books straight and building their brand. Tying all these things together? A need to identify inexpensive or free ways for entrepreneurs to educate themselves in techniques necessary to advance their business.
Lifestyle assistant Patricia Wynn catches up on some paperworkWith an eye on her bottom line and keeping expenses down, Patricia Wynn has taken advantage of online courses with a nominal certification fee to further educate herself as she runs her Hillsborough, N.C.-based lifestyle assistant business, Patricia Services, LLC. 
"I'm thinking about attending some of these seminars in person, or I might even be able to listen to an online version while I'm cleaning for one of my clients." 
Noted Wynn, "Even though I'm not a certified nursing assistant, I was able to go on the myCNAjobs.com website and click on the training section to find online classes. So far, I've taken a caregiver class, one on CPR, another on COVID, one with tips on meal prep for seniors, and a class on the dos and don'ts of dealing with people who are suffering from dementia. Often there is no cost for a course, but [there is] an eight dollar fee if there is a certificate when you complete it."
Wynn, 53, also plans to take advantage of some of the SCORE small business seminars that she sees listed in her email inbox. SCORE is the national organization of business executives that is affiliated with the U.S. Small Business Administration. Wynn has had a good experience with her SCORE mentor, Maxine Stern, and many of the seminars offer helpful business tips for free or a nominal cost.
"I'm thinking about attending some of these seminars in person, or I might even be able to listen to an online version while I'm cleaning for one of my clients," said Wynn.
Finding Ways to Network 
She also recently learned that her Hillsborough, N.C. Chamber of Commerce has annual memberships which start at the entrepreneur level of $300 and include being invited to business events, getting listed as a new company, obtaining referrals, benefiting from advocacy, and networking. Wynn is reviewing information on her local chamber of commerce organization before committing to join.
Patricia Wynn outside the Chamber of Commerce office in Hillsborough, N.CKimberly A. Eddleston, Schulze Distinguished Professor of Entrepreneurship, D'Amore-McKim School of Business, Northeastern University, Boston, said entrepreneurs should, "Search for your local, town or state chamber of commerce on uschamber.com. They offer workshops on all kinds of marketing, ideas on branding, and understanding financial statements. Some are very focused on how to start a business. They could also do community outreach events that might put you in touch with potential customers or other entrepreneurs in your area."
Eddleston, a senior editor of the (EIX) Entrepreneur and Innovation Exchange, which is a funder of Next Avenue, also recommended that new entrepreneurs look for online or in-person workshops sponsored by SCORE or the Small Business Administration (SBA) and websites like frugalentreprenuer.com, which has a listing of courses, tips and tools for small business owners.
She added, "Many universities and community colleges also offer free or inexpensive workshops. If you don't have a business background, you need to understand accounting. You need to know what's costing you money and what's making you money," with your new business.
Opportunities for Education 
Eddleston mentioned that even YouTube has some accounting and bookkeeping informational videos. "You should pick accounting programs that will not overwhelm you — a platform that will offer you basic information so that you can move up and grow" your company, she explained.
In Wynn's case, Eddleston said, "The idea is that she wants to grow, but if someone grows too fast, there can be problems. There are scams out there, and you have to be really careful. Look for reviews when you are looking at online workshops — you want to be aware of whether they are trying to sell you something."
Another source that owners of startups can trust would be the Small Business Development Centers and continuing education courses often associated with colleges and universities or nonprofits, noted Eddleston.
"EIX offers free online surveys to assess your (business) strengths and weaknesses and articles written by leading professors," she said.
Eddleston also suggested new entrepreneurs join trade associations. "Their whole purpose is doing research on what are best practices in your industry," she said. "You can see what the trends are, start networking and find out how you might pivot, if necessary."
"I want to show my work ethic. If I tell someone I will be there, they can be sure that I will show up." 
As COVID-19 restrictions begin to lessen, Wynn said she might consider attending some in-person small business workshops as well as the online options.
"I received an email that had information on SBA programs with no out-of-pocket cost at North Carolina Central University, a historically Black college in Durham, and at North Carolina State University in Raleigh," Wynn said. "I just have to see when they are offered and how I could fit attending a program into my schedule."
Keeping a Steady Flow of Work 
Wynn, who continues to maintain her Care.com profile to attract business for her lifestyle assistant company, juggles her weekly and as needed customers ranging from two to eight-hour assignments to keep a steady flow of work.
"Rather than charge a flat fee to clean a house, for example, I prefer to charge by the hour, ranging from twenty-five to thirty dollars. If one customer needs less done, I can try to pick up additional hours from another customer. I love what I'm doing with the cleaning and the cooking — that's why I'm taking my time building the business."
Through research, Wynn learned that a local cleaning company charged $240 for two hours of work with a staff of 4 people. If she works eight hours at $30 per hour, she's also making $240.
The key, commented Wynn, is to "always make sure that you are professional and show up on time. I want to show my work ethic. If I tell someone I will be there, they can be sure that I will show up. Networking is free because clients recommend you to their friends who become new clients."
Ironically, Wynn is making a business out of work similar to what her mother did as a health care private duty employee and domestic when she was growing up in the Hillsborough and Chapel Hill region.
"Back then, my mother said, 'this is not the land of opportunity for us' — meaning for Black people. While there are still some confederate flags flying at certain homes, and home prices have skyrocketed, pushing many Blacks and others that can't afford the real estate out, it's something for me to come back (from Atlanta) twenty-six years later and make a business of being a lifestyle assistant," said Wynn.
This article is part of America's Entrepreneurs, a Next Avenue initiative made possible by the Richard M. Schulze Family Foundation and EIX, the Entrepreneur Innovation Exchange.

The Learning Curve of Starting a New Business

In this series, Next Avenue will follow Patricia Wynn as she embarks on becoming an entrepreneur with her North Carolina lifestyle assistant business. Future installments will note her progress, with advice for her and for other midlife entrepreneurs.For new small business owners like Patricia Wynn, April signifies not only spring but also filing taxes for their startup for the first time. This month marks one year since the establishment of her lifestyle assistant business Patricia Services, LLC in Hillsborough, North Carolina and Wynn says while it is "challenging to have everything gathered for all of the business expenses," she is prepared.
The 53-year-old entrepreneur said having a separate business bank account "to show all of my monthly costs like the Vistaprint for my signage, webpage and domain, as well as how much I've spent for my Care.com account, uniforms, administrative fees, cleaning supplies and office supplies," has been very helpful.
"I think next year I'm going to do the quarterly estimate (tax payments) for the business, so I'll know what I owe ahead of time." 
In addition, Wynn said she has been careful about keeping track of her receipts, mileage and home office costs, as well as her earnings from each client, by recording the information in an administrative book of printed documents and using the Everlance app on her phone to compute mileage for work-related driving.
She noted, "I've been doing my own personal taxes for several years either using Turbo Tax or Credit Karma. With the business, I will use Schedule C, but also have one of my clients, Susan Crisp, who is an accountant, look over the electronic tax forms before I hit send," said Wynn. 
She added that if Crisp finds errors, she will pay her to make corrections before she files.
Obtaining an Employer Identification Number (EIN)
Following the advice of her SCORE mentor, Maxine Stern, Wynn has obtained an Employer Identification Number (EIN) which she can use on tax forms for the business.
"Moving forward," said Wynn, "I think next year I'm going to do the quarterly estimate (tax payments) for the business, so I'll know what I owe ahead of time."
Stern, a former CPA at Duke University in Chapel Hill, North Carolina, said new entrepreneurs can go to the IRS.gov website to get an EIN for no additional cost.
"The IRS links the EIN with your Social Security number, so they know it is you. The reason having an EIN for business is important is that, for security reasons, you don't want to be giving everyone your personal Social Security number," said Stern.
She added that when it is time for a new entrepreneur to file taxes, "everyone doesn't need an LLC (limited liability company) but they do need to think of themselves as a sole proprietor."
For their business, noted Stern, entrepreneurs can use Schedule C in their personal income tax for filing, whether they file as a single person or jointly with a spouse.
She said that with Schedule C, "You list all of your revenues, meaning any cash or checks (from the business). You must list the 1099 forms separately, and then there will be an area where you are asked about all of your expenses."
In terms of federal, state and local taxes, it is very important that small businesses show their legitimate expenses so their tax is based on their actual profit.  
According to Stern, "Most small businesses file (taxes) once a year. Once they have a lot of tax liability, they have to send in estimated taxes four times a year. I think one of the most important things that a new business can do is hire a bookkeeper. It's less expensive than a CPA. The bookkeeper can help the new business owner be organized and coordinate with a CPA if one is hired at tax time."
The Benefits of a Community-Based Bank 
Entrepreneurs might also get more personal attention if they set up company accounts for their small businesses at community-based banks, according to David Deeds, Schulze Professor of Entrepreneurship at the University of St. Thomas Opus College of Business in Minneapolis and editor-in-chief of the (EIX) Entrepreneur and Innovation Exchange, which is a funder of Next Avenue.
Small business owners, said Deeds, "should use a small community-based bank rather than a large national bank. A smaller bank will help you understand when quarterly payments must be made and may have referrals for a bookkeeper."
Patricia Wynn Keeping track of all deductibles is also key for a new startup or LLC, noted Deeds. "Make sure you keep track of your mileage and use federal mileage deductions. Keep track of parking expenses, too. This is why you need a business account with a separate credit or debit card." The IRS business mileage rate for 2021 was 56 cents per mile.
For small startups or LLCs, there are a variety of opportunities to lower taxes through deductions. The IRS allows these businesses to deduct $5,000 in startup and organizational costs if their total startup costs are $50,000 or less. These costs can include research and development investigating whether the business idea is viable, training employees, and ordering supplies. 
According to the IRS, if a small company's startup or organizational costs exceed $50,000, then the amount of the allowable deduction will be reduced by the overage.
Other deductible areas include, but are not limited to, business property rent; auto expenses connected to business use; rent and depreciation on equipment and machinery; advertising and marketing; business insurance; travel expenses including local tolls; office supplies and furniture; the home office; computer software for the business; hiring legal or accountant professionals; and retirement plan contributions.
When it comes to filing taxes, Stern says there are some common mistakes that entrepreneurs with new businesses may make. For example, it is important to realize that each startup has expenses that are unique to their particular type of business.
"The federal government says if you are buying something that you wouldn't otherwise use for anything outside of the business, then it is a legitimate business expense," she noted.
Relying on Her Strong Organizational Skills 
Stern mentioned that there are two ways to calculate the home office deduction. Both are based on the percentage of the square footage of your home used for business. One is a percentage of your actual home office expenses; the other is a simplified formula using a specific dollar amount per square foot.
"Now I'm taking something that I learned earlier and using it for something of my own." 
Wynn credits her previous career as a general manager at two franchise restaurants with giving her strong organizational skills.
"I learned about keeping track of profit and loss from years of working at McDonald's and Wendy's. We made projections and looked at maintenance, repair and labor. Now I'm taking something that I learned earlier and using it for something of my own," she said.
Both Deeds and Stern stressed the importance of entrepreneurs being organized when it comes to separating personal and business expenses. According to Stern, using a financial tracking program over the short and long term might assist new business owners in taking an honest view of their startup.
"People don't always see everything in an objective, analytical way," she said, and tracking their business expenses, revenues and profits might help them do that better.
Deeds said having a separate account to record business expenses not only helps Wynn figure her taxes better but also "makes her set to grow."
He added that as a lifestyle assistant providing cooking, cleaning and sometimes caregiving to clients, "she is in a growing market — helping people to age in place, which is more and more necessary as boomers age."
This article is part of America's Entrepreneurs, a Next Avenue initiative made possible by the Richard M. Schulze Family Foundation and EIX, the Entrepreneur Innovation Exchange.

Tax Tips for Entrepreneurs with New Small Businesses

The Retirement Gap is a real-life problem. Learn how to prepare for whatever retirement may look like for you.

Growing a business means managing change. Read how entrepreneurs like you have done just that and found resources to succeed.

Nationwide workshops and festivals offer community for aging artists

There is power in talking openly about mental health and mental illness. Featuring expert insight and personal stories, find support and resources on how to challenge stigma and rethink mental health as we age.

Perceptions on Wealth in Retirement

Navigating Change

Art + Aging in Community

Talking About It: Aging and Mental Health