Single-owner per-diem RN, LPN, and CNA agency filling last-minute shift gaps at Louisville's skilled-nursing facilities, dialysis clinics, ambulatory surgery centers, and FQHC clinics — not the three big hospital systems.

Start with the three-system anchor weight. Norton runs roughly 17,000 to 18,000 employees across five adult hospitals plus Norton Children's. UofL Health is the academic medical center system at 13,000 to 14,000. Baptist Louisville carries about 3,800 employees and 519 beds at 4000 Kresge Way. Each runs an internal float coordinator first, then a vendor-management system — Medefis, ShiftWise, or a homegrown tool — that broadcasts open shifts to contracted enterprise agencies at negotiated bill-rate tiers. The founder agency does not enter at this surface.

Jefferson holds roughly 40 to 50 skilled-nursing and assisted-living facilities. Trilogy Health Services is headquartered at 303 N Hurstbourne Parkway and runs about 120 facilities across Kentucky, Indiana, Ohio, and Michigan, with Jefferson sites at Forest Springs, The Springs at Stony Brook, The Lafayette, and Westport Place. Signature HealthCARE is headquartered at 1000 Stewart Drive and operates multiple Jefferson facilities. Masonic Home of Louisville, Treyton Oak Towers, Wesley Manor, Nazareth Home, Episcopal Church Home, Atria Senior Living, and Sunrise Senior Living each operate one or more Jefferson sites. ScionHealth, the LTAC and community-hospitals successor to the legacy Kindred footprint, runs long-term acute-care beds in metro Louisville. Frazier Rehabilitation Institute on Abraham Flexner Way is the UofL Health rehab anchor.

Outpatient demand stacks on top. Jefferson supports roughly 12 to 20 outpatient hemodialysis centers operated mostly by DaVita and Fresenius Medical Care, with hospital-system-affiliated outpatient capacity at UofL Health and Norton. Dialysis clinics run three to four shifts a day on alternating-day schedules and are chronically short of dialysis RN and tech coverage. Jefferson also holds roughly 15 to 25 freestanding ambulatory surgery centers, including Bluegrass Surgery Center and Norton Brownsboro Surgical Center plus specialty orthopedic, ophthalmology, GI, and urology centers.

The FQHC layer is two anchors. Family Health Centers Inc operates multi-site delivery across Jefferson out of administrative offices at 1015 E Indiana Street; Phoenix, East Broadway, Iroquois, Portland, Americana, and Fairdale are all part of the network. Park DuValle Community Health Center at 3015 Wilson Avenue is the second FQHC anchor. Infusion centers at Norton Cancer Institute, Brown Cancer Center, and Baptist Louisville oncology require chemo-certified RNs holding the Oncology Nursing Society chemotherapy and biotherapy card. Hosparus Health at 3532 Ephraim McDowell Drive — the largest non-profit hospice in Kentucky — carries continuous-care per-diem demand.

Galen College of Nursing's founding Louisville campus, UofL School of Nursing, Bellarmine, Spalding, Jefferson Community and Technical College, and Sullivan University each graduate annual RN and LPN classes. A measurable share rotate first through hospital-employed roles and feed agency rosters only after 12 to 24 months of acute experience. The founder agency's recruiting window is the high-flexibility career years: early career before children, or post-retirement returning to bedside work.

The founder agency math runs about 15 to 22 percent gross margin against national agencies at 25 to 30 percent. The nationals carry corporate overhead a Louisville founder does not. A local agency at 15 to 22 percent can underprice the nationals on the SNF and ambulatory tier and still clear $150,000 to $400,000 owner take-home at $3 million to $8 million in placement volume. The SNF Director of Nursing values a recruiter who answers the phone at 2 a.m. far more than a national sales rep in Dallas.

Working Kentucky bill rates as of 2026: CNA at SNF $32 to $44 per hour with clinician pay $18 to $24 (gross margin $7 to $13). LPN at SNF $48 to $62 per hour, pay $26 to $36 (margin $9 to $16). RN at SNF or LTACH $58 to $78, pay $34 to $46 (margin $11 to $20). RN dialysis chronic-shift $62 to $85 (margin $12 to $22). RN ASC pre/post-op $58 to $72 (margin $10 to $18). Surgical-tech ASC $50 to $66 (margin $8 to $14).

Year-1 model (single founder + 1 W-2 recruiter, $500K-$650K capital deployment): target 4-6 active facility accounts (2-3 SNFs + 1-2 dialysis clinics + 1 FQHC + 1 ASC). 18-30 active clinicians at 24-36 hours weekly. Annual billed hours ~25,000-45,000 at blended bill rate $48-$58/hr. Year-1 revenue: $1.2M-$2.6M. Gross margin 18-20% = $216K-$520K. Operating expense (founder base + 1-2 W-2 recruiters + office + software + insurance + working-capital interest) $180K-$300K. Year-1 founder take-home: $80K-$150K.

Year-3 model (founder + 2-3 W-2 recruiters + 1 credentialing/payroll admin): 12-18 active facility accounts; 60-90 clinicians active weekly at 28-36 hours. Annual billed hours ~95,000-160,000. Year-3 revenue: $4.5M-$9M. Gross margin 18-20% = $810K-$1.8M. Operating expense $550K-$1.1M. Year-3 founder take-home: $150K-$300K.

Mature steady-state ($300K-$500K+ take-home): Louisville per-diem agency at $8M-$15M revenue with 4-6 recruiters + credentialing team + ops manager. Above $15M the agency typically pivots into travel-nurse contracts or specialty acute/OR/peri-op placement — at which point the lane becomes the AMN-style game and gross margin compresses.

Binding capital constraint = payroll-funding. Agency pays clinicians weekly (Friday is the KY standard) and bills facilities net-30 — roughly a 6-week working-capital cycle carrying 4-5 weeks of payroll. At $2M revenue Year-1, weekly payroll runs $32K-$38K and working-capital need is $140K-$190K. At $5M revenue Year-2, weekly payroll runs $80K-$95K and working-capital need is $340K-$460K. Most founders run an AR-secured bank line of credit (Republic Bank, Stock Yards Bank, Forcht Bank, First Financial Bank at SOFR + 250-450 bps against 75-85% of AR <90 days; rate sheets pending verification).

Workers' comp class code 8833 (nurses) + 8865 (home health) at modal premium $4-$8 per $100 of payroll. At $2M payroll Year-1, WC premium = $80K-$160K, typically paid pay-as-you-go. Professional liability + general liability + cyber ~$15K-$35K annual. Background-check + drug-screen at $35-$65 per onboarding (Checkr or Sterling). Total Year-1 capital deployment of $500K-$650K covers working-capital LOC float + WC + E&O + software + 2 recruiter desks + founder draw bridge + 6-month operating reserve.

• Trilogy Health Services (Louisville HQ, 303 N Hurstbourne Pkwy)

  Multi-state SNF and senior-living operator

  Institution

  Operates Forest Springs, The Springs at Stony Brook, The Lafayette, and Westport Place in Jefferson; the VP Talent Acquisition plus each facility's executive director and director of nursing run the agency-vendor conversation.
• Signature HealthCARE (Louisville HQ, 1000 Stewart Dr)

  Multi-state SNF operator

  Institution

  Multiple Jefferson facilities; the VP Talent plus each facility administrator and director of nursing are the vendor contacts.
• Masonic Home of Louisville, Treyton Oak Towers, Wesley Manor, Nazareth Home, Episcopal Church Home

  Nonprofit SNF and CCRC operators

  Institution

  All members of LeadingAge Kentucky. Each site's chief nursing officer or director of nursing runs vendor conversations directly.
• ScionHealth (Louisville HQ)

  LTACH and community-hospitals operator

  Institution

  Successor to the legacy Kindred restructure; operates long-term acute-care beds in metro Louisville.
• Family Health Centers Inc (admin 1015 E Indiana St) and Park DuValle (3015 Wilson Ave)

  FQHC delivery

  Institution

  Family Health Centers runs six Jefferson sites; Park DuValle carries about $46.4 million in HHS funding on record. Both buy clinic-RN, LPN, and medical assistant per-diem coverage.
• DaVita and Fresenius Medical Care

  Outpatient hemodialysis

  Out-of-county

  Corporate offices sit in Denver and Waltham, Massachusetts; clinic-level facility administrators or clinical managers are the procurement counterparty in Jefferson. Both carry a chronic dialysis RN and tech shortage.
• Hosparus Health (3532 Ephraim McDowell Dr)

  Hospice

  Institution

  Largest non-profit hospice in Kentucky; carries continuous-care-visit per-diem demand. VP of Clinical Operations runs the vendor conversation.
• Kentucky Board of Nursing (312 Whittington Pkwy Suite 300, Louisville)

  State licensure regulator

  Institution

  Runs Nursys license lookup and enforces 201 KAR 20:411 against staffing agencies; reachable at (502) 429-3300.
• AMN Healthcare, Aya Healthcare, Cross Country, Medical Solutions, Trusted Health

  National travel-nurse and per-diem agencies

  Out-of-county

  Hold enterprise contracts with Norton, UofL Health, and Baptist through Medefis or ShiftWise. The founder lane routes around them.
• ShiftKey, Clipboard Health, CareRev, IntelyCare

  Gig-economy clinical marketplaces

  Out-of-county

  CNA-tier shift marketplaces with a growing Kentucky footprint. The defensive position for the local founder is service density — credentialing, payroll, facility QA, and 2 a.m. issue resolution — that an app cannot supply.

The primary lane is an operator-founder paired with a contracted Kentucky-licensed clinical-supervisor RN. The founder does not need to hold an RN. The agency does need a contracted clinical-supervisor RN in good standing per Nursys lookup to sign credentialing files and respond to facility QA from day one. The founder runs facility-account development, working capital, payroll, billing, and the recruiter team. The supervisor RN signs clinical credentialing and runs scope-of-practice review on every placement.

A second common path is a returning-home healthcare operations professional. A Louisville-native former hospital staffing manager, clinical recruiter, or healthcare-operations leader who spent five to ten years at one of the national agencies or inside one of the big-three procurement offices and is bringing back the recruiter network and credentialing competence.

The third path is an existing healthcare-ops operator bolting on per-diem. Post-acute administration, home-health agency, or ASC management background; real estate, payor-billing infrastructure, and clinician network already in place. The per-diem book is a margin-expansion line.

Routing discipline against the big three. Norton, UofL Health, and Baptist each operate a vendor-management system plus enterprise contracts with the national agencies. The founder agency does not pursue those accounts in years one through three. The 35 to 50 procurement principals one tier below — SNFs, dialysis clinics, ASCs, FQHCs, infusion centers, hospice — are the entire book. Cross-sell into hospital-system supplier-diversity programs (Kentucky MSI or WBE certification) is a separate channel that can run in parallel for ancillary, non-clinical work.

Secure a working-capital line of $300,000 to $500,000 at terms supporting the six-week AR cycle before the first clinician is placed. Republic Bank, Stock Yards Bank, Forcht Bank, and First Financial Bank are credible Jefferson-resident lenders. Without the line, the agency runs out of payroll cash before the first 30-day invoice clears. This is the single most important pre-launch deliverable.

• — The CHFS Office of Inspector General long-term-care, ASC, and home-health licensure rosters filtered to Jefferson — the complete operator list with bed counts and ownership. We have not pulled the current roster.
• — The competitive inventory of Kentucky-licensed clinical-staffing agencies in Jefferson — revenue bands, headcount, specialty focus.
• — Norton, UofL Health, and Baptist Health VMS configuration and the enterprise-agency tier rosters underneath. Relevant only to confirm the big-three lane stays closed.
• — Facility-level clinical leadership rosters at Trilogy, Signature, ScionHealth, Masonic, Treyton Oak, Wesley Manor, Nazareth, Episcopal Church Home, Hosparus, DaVita, and Fresenius.
• — Galen, UofL Nursing, Bellarmine, Spalding, JCTC, and Sullivan 2024 and 2025 nursing-program graduation counts by RN, LPN, BSN, and ADN path.
• — KBN 2026 staffing-agency posture and 201 KAR 20:411 disciplinary actions from 2024 through 2026.
• — Confirmed 2026 Kentucky eNLC participation status, the CMS SNF minimum-staffing final-rule litigation status, and the Kentucky Medicaid SNF rate-update cycle through 2027.
• — Current Louisville-metro penetration of ShiftKey, Clipboard Health, CareRev, and IntelyCare in CNA and RN per-diem segments.
• — Republic Bank, Stock Yards Bank, Forcht Bank, and First Financial Bank 2026 rate sheets and underwriting standards for clinical-staffing borrowers seeking AR-secured lines.
• — Workers' comp class-code 8833 (nurses) and 8865 (home health) modal premium rates for Kentucky clinical-staffing employers as of 2026.

Tonight, this week, this month — in that order. Each step produces a yes/no or a number, not a deeper understanding.