PMHNP practice

[IDNP]

Hello All,

I am a fairly new to PMHNP practice, working for an organization who is fairly knowledge deficit to the area of behavioral health. I am looking to get some insights on how others run their psych practice. How many patients do you see a day? How are your appointments scheduled. At present we schedule follow ups on 30 minutes slots and 60 minutes for new patients. No show rate is high I would say 30%. How do you compensate for the high no show rate for mental health patients? . I am feeling pressure from administration about productivity etc. It's not my fault sometimes patients do not show up. Double booking is concerning because sometimes ALL patients show up.

Thank you,

[IDNP]

I believe part of the problem is being compared to the medical practitioners and how many patients they see when psych is totally different.

[verene, MSN]

Sounds like a challenging situation and you are correct that part of the problem is likely this organization's inexperience with offering behavioral health services and with comparing psych to medical in terms of patient load and time constraints on appointments.

Generally speaking 60 minute intake and 30 minute follow up is fairly normal in the psych world (though 90 minute intakes are really nice for peds and for complex patients). The bigger issue seems to be the high no-show rate -- What are the largest barriers to patients making appointments? What can the organization do to address these? Is there also a high no show rate on the medical side of the clinic and, if yes, how do they handle it on that side? Are you an FQHC or a private clinic?

As a student in outpatient I think usual load was 12-14 day with no more than 2 of those being intakes? Currently I work inpatient and my panel caps at 13 unless I'm covering for another provider - then I can have as many as 25 - but I am not obligated to see all patients daily.

[DrCOVID, DNP]

I'm in an outpatient independent practice. We have 2 front desk people that screen and call and manage appointments. Patient's are dropped if they no show 2 times. No exceptions. She will often fire people that are highly disagreeable. With those 2 things she has low no show rates. She takes a variety of commercial insurance, including gov programs and cash. She grossed 330k last year minus all her expenses. Routine patients are ~15m and new intakes 45m. However, she has the best lightweight charting I have ever seen.

I also worked at a FQHC which does 30m for routine and 60m for new folks. There the providers are salaried and therefore paid regardless of who shows, but it is much lower I have heard 90-120k salary ranges. No shows were much more common probably 20% if I had to guess.

In the hospital where I was rotating, things have changed, and it is hard to keep track of who sees who because the MD and APRN would divide up patients between the them and then the MD would go to the outpatient program usually to see people. He was offering to start a new grad at 130k and his senior NP was at 150k. I have heard their workload went up a lot; before I would see about 10 inpatients, now it is like 15-20, because a large mental health clinic closed here.

IE, as a provider, things are highly variable depending on where you work.

[mangopeach]

I work in community mental health. I've seen as many as 19 patients in a day. Though my average is around 15. Med management is 20 mins. New patient 60 mins. I am salaried so get paid the same if only half of my patients show up or all of them show up.

We have a lot of no shows. We do walk ins to compensate for the no shows. Which makes your day really unpredictable! I've been a working NP for less than a year so things take me longer than some of my co-workers. Its very rare the person that comes in that is psych med naive. Many have tried "everything and nothing works" so sometimes coming up with a regimen takes more time and goes over 20 mins.

I used to dislike walk ins, but I am warming up to the notion now. While I am salaried, we do get production bonuses so having walk ins help. As we have gone telemed due to coronavirus, I am liking that option more as well. We have a contract with the local county jail so I was already doing telemed with jail patients 2hrs, once a week. Now that we are strictly telemed, I like that option more as well. So many clients ask for late evening or weekend appts. We close at 5. Many of our clients don't have PTO, so asking them to come in when they have to work, is really difficult. Looking to ask the powers that be if they will add late evening and weekend tele-med service. But I'm waiting till its time for me to renew my contract and ask not to be salaried at that time.

Maybe those ideas may be helpful to you. Consider walk ins and tele med.

[IDNP]

Thank for sharing,

How are psych NPs dealing with overly anxious patients with this covid crisis situation?

I have found patients are very anxious, many asking for anxiety meds. People are panicking. those who are laid off and ordered to stay home are having even a harder time. Besides providing re-assurance and support.

Thanks

[IDNP]

On 3/28/2020 at 2:52 PM, mangopeach said:

I work in community mental health. I've seen as many as 19 patients in a day. Though my average is around 15. Med management is 20 mins. New patient 60 mins. I am salaried so get paid the same if only half of my patients show up or all of them show up.

We have a lot of no shows. We do walk ins to compensate for the no shows. Which makes your day really unpredictable! I've been a working NP for less than a year so things take me longer than some of my co-workers. Its very rare the person that comes in that is psych med naive. Many have tried "everything and nothing works" so sometimes coming up with a regimen takes more time and goes over 20 mins.

I used to dislike walk ins, but I am warming up to the notion now. While I am salaried, we do get production bonuses so having walk ins help. As we have gone telemed due to coronavirus, I am liking that option more as well. We have a contract with the local county jail so I was already doing telemed with jail patients 2hrs, once a week. Now that we are strictly telemed, I like that option more as well. So many clients ask for late evening or weekend appts. We close at 5. Many of our clients don't have PTO, so asking them to come in when they have to work, is really difficult. Looking to ask the powers that be if they will add late evening and weekend tele-med service. But I'm waiting till its time for me to renew my contract and ask not to be salaried at that time.

Maybe those ideas may be helpful to you. Consider walk ins and tele med.

We started offering telemedicine this week. TOday was my first day. I am a bit confused about billing. Some patients are unable to do video meeting. We are using zoom which is not the friendliest as it requires patient to download app. Is there a specific platform you use that is more effective?

I did had a great show rate today. Defitinely helps.

[DrCOVID, DNP]

Don't go by my word on this but here in TX my APRN is saying the gov has approved routine appointment billing for phone/video calls due to the pandemic. I am sure this depends on state government/board w/e.

[ToFNPandBeyond]

We've been using doxy.me and it has been super user-friendly. It's simple to set up an account for providers. From there, your MA can send the link to patients and they type their names and are good to go.

So far, insurances have been lenient regarding reimbursement. Even medicare in CA is allowing telemedicine from home and are reimbursing for it, so long as we provide proper documentation.

[AtomicWoman]

On 4/6/2020 at 11:15 PM, ToFNPandBeyond said:

We've been using doxy.me and it has been super user-friendly. It's simple to set up an account for providers. From there, your MA can send the link to patients and they type their names and are good to go.

So far, insurances have been lenient regarding reimbursement. Even medicare in CA is allowing telemedicine from home and are reimbursing for it, so long as we provide proper documentation.

My husband had a new patient specialist appointment via telemedicine last month. I looked at his EOB and Medicare approved a whopping $54 for the visit, even though the CMS website claims "These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits." $54 for a new patient visit is not a sustainable model for most specialty practices. Or primary care practices, for that matter.

[IDNP]

That is definitely not sustainable!