PMHNP Unforeseen Duties

[MH2206]

Hi to all,

I've been working at an outpatient clinic in a rural area for a few months now. This is a great position and I enjoy the base population I work with, but there have been a few unforeseen duties I didn't expect to encounter.

First, I've been asked to travel away from our clinic (about 45 miles) to a nursing home to perform med consults on about 10-12 consumers close to once or twice per month. This has been great experience, but the population is much more acute with significant medical comorbid conditions. The decision making process is much more difficult than the outpatient population I work with and was not addressed in the contract. The nursing home has also asked me to prescribe and slightly pressured me to "be available" when they need to fax a refill request. This is a bit worrisome from a legal standpoint as I don't know if the policy covering our agency will cover for services rendered to a different agency.

Second, the initial agreement was that there would be no on-call. Since starting, I've received several phone calls from the on-call crisis line, staffed by our LCSW's, with med questions. Our initial agreement was to work 40 hours Tuesday through Friday. I typically use Monday as a "catch up" day and don't mind these calls during that time. However, they have been calling more on Saturday and Sunday evenings with questions and prescription requests I don't feel comfortable giving without seeing the individual in person. Would this be considered "on-call" or just something that is to be expected with the position?

The reason I bring this up is because I'm wondering if I should request to be better compensated. I don't mind these tasks, but was a bit thrown off when considering what my base contract was agreed upon and what I am actually doing. Any thoughts would be greatly appreciated!

[Back2SchoolRN]

I'm just a student PMHNP, but I would highly recommend you meet with collaborating physicians and let them know of your concerns. Negotiate what "no call" is allowed to mean: What did you think it was, when you accepted your current terms? What you are doing sounds somewhere in the middle, but essentially doing lighter call duties (yet with all the usual responsibilities for those decisions) without pay.

Also make sure you have policies and procedures in place agreed upon in writing detailing your responsibilities, and what your/their insurance covers. What do they think about you prescribing without seeing a patient in person? Would they do it, if unfamiliar with the patient? Under what circumstances?

If the answer is mostly no, then yours should be no, too....In that case, the on-call person should be picking it up, because going in even for a minute, having your social life interrupted, or being awakened after reasonable waking hours (before 9p, for example) definitely IS call! The whole point of rotating on-call responsibility is to be able to turn off your cell or beeper and not worry a bit.

You could allow the occasional exception; maybe you've just done the admission work-up and initial orders, and you forgot to cover one situation or need such as minor pain or sleep med. Or the nurses or LCSWs have paged and paged the on-call provider, but no reply. (In which case have a firm talk with the provider, if it happens twice.) And someone else who is officially on call can call you for input if you know the patient much better, but they should take the nurse's and LCSW's calls and try to handle them alone first.

If the ECF wants you to be available, same thing--and the nurses need to be following POP in contacting you, (such as how recently a provider last saw the patient) and your MDs willing to back you. It may also be that if you are too available, primary medical care providers will be bypassed in favor of contacting you, even when the med order is something primary providers have done or could do, at least short term, such as a sleep med.

Also, 45 miles is almost the limit of distance the collaborating MD can be from the where you are practicing in many states--how far is it, exactly, from your clinic and the MDs' homes, not your home, to the ECF--EVERY ECF? CYA rules apply, and if you agree taking calls is not "on call, make sure the MDs are doing the same when you're really on call; otherwise you are doing call duty without pay.

Above all, get that backing, make sure the MDs would do the same, check the distance if a law applies....take care of your license first. If the MDs don't want to pay for your taking extra calls, don't allow them. It is always better when a prn is needed for unexpected behavior that a provider see them in person, than that you or any provider are called just because you have seen them in the past and the on-call provider hasn't yet. Psych patients cam be volatile and they can fool you; that's why they're in there (as you know).

Hope this gets you thinking about self-protection as well as proper compensation, which you also deserve....I'm no expert, though.

[Whispera, MSN, RN]

If you write prescriptions, you must be covered at each specific facility, if you're prescribing anything that on any of the "controlled" lists. Even if one facility is a branch of the other, you must have each and every license covered on your prescriptive authority with the DEA. I know this because I worked for a big conglomerate, and prescribed at 3 branches of it. I had to specify each to the government.