PMHNP Scope of Practice

[Psyched-85]

Hello,

I am a recent PMHNP graduate working my first job in residential rehab (6 week program). I was informed last week that part of my role expectations is: 

-Serving as the primary outpatient provider for patients engaged in MHRRTP

-Provide continuity of care for assigned patients working in consultation with staff

-Evaluating patients physical and mental health to identify health care needs and refer patients to appropriate level of care.

The above three expectations do not concern me as they seem appropriate.

However, they continue to state 

"In addition to addressing psychiatric care, the NP provider must address routine medical and physical concerns, within the scope of a nurse practitioner for all patients admitted to residential rehab and coordinate care with the appropriate primary care and specialty providers when concerns are assessed to be beyond the NP's scope of practice. The NP should not send patients to or request orders from Primary Care or outside specialty care in instances in which a medication change or other in-scope interventions wouldn't drastically change the patient's treatment plan. This ensures appropriate resource utilization, ensures continuity of care, preserves vital relationships with other services within and outside the mental health division, and prevents unnecessary delays. 

Communication will be provided to all residential staff that all provider needs will start with residential NP's being signed on notes for initial review (without PCP or specialty providers being alerted). Communication with PCPs or specialists will be initiated by residential providers rather than RN's (with majority of communication being updates on changes made to patients treatment plan or attempts to coordinate care, not requests for PCP or specialty providers to place orders, etc). The NP's play a very important role in the medical and psychiatric care in the residential program. Similar to the psychosocial care coordination provided by the residential case managers, the residential providers are the point people for all the medical and psychiatric concerns of patients enrolled in residential treatment. There are many resources available in primary care and specialty support but it all starts and ends with residential providers."

There are many parts to this that I do understand and feel is appropriate such as assessing the Vet and determining what I can address as a PMHNP and what medical concerns require the attention of their PCP and/or specialists. We are located on campus with hospital, clinic, ED, etc and all patients either already have their doctors on campus or are assigned a PCP for their stay to manage medical concerns. My concern with this job expectation is that in some instances it sounds like as the PMHNP I am suppose to be addressing and managing medical concerns and essentially just updating their PCP or specialists with treatment plan changes I have made and in cases in which it may be complex simply collaborate with them and make the recommended adjustments myself since they do not want me asking their pcp or specialists to put in orders, etc. Seeing as we are located on campus, patients are allowed to go see their providers and keep an appointments that they may have as they remain on the facility grounds. I do not feel that managing someone's medical problems is within my scope of practice as I have not received additional training and am not dual certified as a FNP. Am I misunderstanding the email I received or does it seem to contradict itself? Any insight would be appreciated.

Thank you

 

[onedayatatime100]

I work in primary care as a FNP and have worked in the PRRTP as an RN... 

What I take from this --- It is up to YOU as the provider, to involve other medical providers (like the hospitalist or PCP)  - as needed if medical problems arise during the admission to the PRRTP.  The way the charting system is -- the nurses working on the floor can easily tag the PCP in the note.. they don't want that to happen since you are overseeing the care during their residential admission.. you can decide if it is simply a medication refill of their medical med that you feel comfortable refilling (in your scope) or if you need to contact their PCP. Likewise -- can you treat their dermatitis or do you need to place a consult for the hospitalist? Your discretion. 

[Psyched-85]

Thank you for replying. I really appreciate that you took the time. We have continued to have more meetings this week regarding this email and more or less what you said was explained to us. We have ran into some issues this week and have been trying to navigate them and coordinating with various departments but hopefully this gets easier with time and experience. Thank you again!

[egg122 NP, MSN, APRN]

They may be getting at the idea that the person is in the 6 week residential program and focus should be on the residential treatment and not in issues that can wait until discharge- for example long standing acne, chronic back pain without signs of a major neuro issue, OSA that the patient is aware of but never got a CPAP, routine dental care, etc. Essentially, things that can wait until discharge should wait until then. It was my experience in one of these programs that patients had not kept up on their routine health for a while then had the expectation that this would all get addressed in the residential program but they would either be missing substantial parts of the program or asking for things that required a lot of resources that this program was not set up to do. Also, if a patient has controlled chronic issues, like HTN or DM, it is reasonable for you to order the meds be continued as you might with an inpatient psych admission. It would be appropriate to consult primary care for uncontrolled diabetes, uncontrolled HTN, infections, etc.