Chronic care at retail clinics?

[msn-fnp09]

I was at the local Walgreens pharmacy, waiting to pick up my prescription, and I was browsing the list of services offered at the clinic inside the store. I noticed that the options include diagnosis and treatment of chronic illnesses, such as diabetes, hypothyroidism, hypertension, depression, and COPD. Is this really a good idea?

Do any providers here work in a retail clinic that provides chronic care services? What has been your experience with this? Do patients really go to these types of clinics for these services? What does everyone else think of this practice?

I absolutely think that these illnesses are well within the scope of the nurse practitioner to diagnose and treat in the primary care setting, unless they are truly complicated, in which case any prudent PCP would refer them to a specialist. It just seems like a bad idea to offer these services as part of a menu of specific services, next to sore throat and flu. What kind of follow-up will these patients have? What kind of evaluation? If a patient can go to a store clinic for these types of services, does it not discourage them from establishing a PCP? If there is no PCP overseeing their overall health, is something not bound to get missed?

Most of the in-store clinics I have seen have only one person working on any given day. Not to mention, a seemingly-endless list of patients waiting to be seen. Some of them have an assistant, but most do not. How can a solo provider manage all this?

Just really curious to hear what others think of this practice and if anyone has experience to share.

[futureeastcoastNP]

I think it depends on how it's being managed. If it's a situation where the NP is seeing them once, putting them on a BP med, and then sending them off without any follow-up, yes it's a bad idea. If the NP is doing the initial testing and then referring to a PCP for mangement, it's a great idea.

[newFNP2015]

From what I have heard about most retail clinics, the NP is responsible for doing pretty much everything his/herself which makes follow-up more difficult. In this type of practice, I just don't know how they could be a consistent PCP for chronic patients. If they want to make an initial diagnosis and refer to a PCP, go for it. I also don't know the data on how long these providers stay in these positions or how many shifts per week they work which could be of concern for people wanting the same provider for long periods of time. If I had a chronic condition, I would not feel comfortable leaving it to chance who I might catch for an appointment at a retail clinic. That being said, I would have no problem going to one for an acute illness if I did not have a PCP or if my PCP didn't have any openings.

[goofeegirl]

I currently work at a retail clinic where the NP is the sole provider. Some chronic conditions are more easily diagnosed and treated while others definitely require more advanced tools. Honestly, it's so busy at the clinics in my area that I can't imagine offering more services. People wait up to 3 hours to be seen and this is in the more suburban areas. The clinics in the city have longer wait times.

When I go see a specialist for my own needs I really prefer seeing the same provider. With the rotating schedules that we have, the patient may not have this continuity.

Just some thoughts on the topic.

[SHGR, MSN, RN, CNS]

Personally I have no problem with this. I think NP's are well suited to chronic condition care such as DM and HTN. For people who pay out of pocket, these retail clinics offer transparent realistic pricing for services and convenience.

If a person follows up as directed (every three or six months), I think this is a great solution. Plus the NP is right by the pharmacy and can check whether meds are being picked up at the right intervals. Education about sharps disposal? Pick up a red box right there (too bad, at least in my area NONE of the Walgreen's accept used sharps).

I actually saw two positions for case managers through Walgreen's currently posted. It would seem they are expanding their market.

[BostonFNP, APRN]

I have several colleagues that work in retail clinics.

The wording on their chronic disease statement is tricky. They are allowed to "identify" common chronic diseases and refer to a PCP for treatment. As far as I know they are not "managing" those diseases....

I feel that all those NPs are capable of doing it, and it a great place to identify those diseases, I am not sure it's the right setting for actual management.

[PatMac10,RN, RN]

I have several colleagues that work in retail clinics. The wording on their chronic disease statement is tricky. They are allowed to "identify" common chronic diseases and refer to a PCP for treatment. As far as I know they are not "managing" those diseases.... I feel that all those NPs are capable of doing it and it a great place to identify those diseases, I am not sure it's the right setting for actual management.[/quote']

I agree with this.

[msn-fnp09]

I with you BostonFNP. I would not even give it a second thought if all they were doing was identifying the diseases and referring to a PCP. However, the website of the Walgreens clinic specifically states monitoring and management. If walgreens is doing it, the others are sure to be close behind, so they can stay competitive.

Like I said in my original post - the NPs are perfectly capable of managing these chronic illnesses, but it seems to me that this is just not the right setting in which to do so. As Back2schoolmurse pointed out - chances are high that patients wouldn't even see the same provider on subsequent visits.

[BostonFNP, APRN]

It varies by state what the retail clinics can do, what state at you in?

[msn-fnp09]

I am in Tennessee

[BostonFNP, APRN]

As far as I knew, they would "diagnose and treat" by making a diagnosis then counseling on lifestyle management and held finding a PCP, not the actual pharmacological management. This may have changed, or will change.

[Juliefin, BSN, MSN, APRN, NP]

So, I work in one of the clinics at Walgreens and feel I can therefore address this topic. First. walgreens is just beginning to delve into chronic care management and it is not something they have done without a lot of thought. Yes, we do emergency refills etc but the chronic care management is beyond this, obviously. As we all know, nurse practitioners are well trained to manage chronic conditions. Just because it is being offered in a convenient care setting does not mean the standards change. NPs at Walgreens have the capability to order labs, order EKGs, make referrals, do POC testing in addition to outpatient labs etc. I am not limited in my ability to appropriately manage a chronic care pt because I work there (I cannot speak for other convenient care companies). Also, my patients can make appointments and they can choose to see me or my coworker. Our clinic is managed by 2 NPs and we rotate days. So, there is consistency in providers for our patients. We are there EVERY day of the year except Christmas and Thanksgiving so we are very available. Our patients have a call center to call if they need to talk to a provider and they get a call back the same day from the NP working. Also, the particular clinic I work at is the most busy (for Walgreens) in our area and I still feel this is manageable.

Keep in mind that, despite the ACA, there are still a lot of uninsured or underinsured patients out there and we are often a more affordable option for patients that will not go to a physician practice because they cannot afford it. In addition, because we work in the community, a lot of people get used to us and feel comfortable coming to us instead of a physician practice. Obviously, if a patient is beyond what I feel comfortable managing, I do encourage them to get hooked up with a PCP. We are NEVER trying to take patients from their PCP, we simply are offering another option for those who would otherwise not go anywhere.

Having said all of that, I feel like I should "confess" that when I first took this job out of convenience a few months back (got married, moved an hr away from my previous practice) I felt like I was taking a "lesser" job because it was located in a store. I could not have been more wrong. Again, I can only speak for Walgreens, but I will say that they really, really push evidence based practice and guidelines, following HEDIS guidelines, appropriate billing and coding etc. I get weekly chart reviews from my collaborating physician, quarterly peer reviews, weekly reviews of my billing practices etc. In addition, Walgreens does NOT use algorithms to tell the NP what to prescribe, labs to order etc like some other companies do. I decide how to manage my patients, no one else tells me what to order, pressures me to order antibiotics etc (in fact quite the opposite). I'm actually glad I made the change and work here!

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