PMHNPs - also doing primary care?

[myelin]

Hi everyone, I have a quick question. I was meeting with a student who is in the PMHNP MSN program that I am due to start next fall, and she made some interesting comments. She basically said that PMHNPs can sometimes be expected to do a bit of primary care, depending on the environment (maybe community mental health clinics?) Does anyone know if that is within PMHNP scope of practice or does it depend on the state?

She said that if there is no one to refer to, and if you put them on meds that cause physical problems (like prescribing an antipsychotic and having the patient develop type 2 diabetes), that it is then up to the PMHNP to manage that care, including managing the diabetes, etc, until the patient is able to see a primary care provider. She also made it sound like sometimes PMHNPs will manage physical illnesses if they have a psych component, or just if it's easier for the patient to see one person instead of having to go to two appointments. Has anyone seen this before? I assumed that as a PMHNP I'd function similarly to a psychiatrist and manage psych meds only. Does anyone know if PMHNPs also do some primary care? Does it depend on the setting?

[kris_10]

I can't answer your question, but I do have a question to ask--do DE programs train you on generalist primary care at all? i.e. in the psych MSN track would you learn how to manage diabetes...?

[myelin]

I can't answer your question, but I do have a question to ask--do DE programs train you on generalist primary care at all? i.e. in the psych MSN track would you learn how to manage diabetes...?

I know we all get the same "core" training where we learn advanced health assessment skills and health management (I would assume that includes diabetes). Also, the DE part of it is over by then... we start our MSN alongside the "normal entry" RNs.

[traumaRUs, MSN, APRN]

Ugh - I think you might find that you could manage physical complaints only until they get to a primary care provider, ie one week.

I have several schizophrenic, institutionalized dialysis pts who got their kidneys fried by too much lithium. I sure as heck wouldn't want their psych to manage their dialysis and hypertension.

[twinkerrs]

The way I read the scope and standards of practice, my answer is no we as pmhnp (stb in my case) are not supposed to be managing diabetes care or primary care type issues. I will get out my ss book and give you the direct quote later.

[elkpark]

Psychiatrists do not manage "psych meds only." Every psychiatrist I've worked with over the years (in inpatient settings) have done some primary care, i.e., dealing with the medical issues of the individuals on inpatient psychiatric units, and, in outpatient settings, they're responsible for the interaction of psych meds with whatever medical meds and issues the client may have, and to manage the medical side effects/problems related to psych medications they've prescribed. In my experience, that's considered part of the basic scope of practice of psychiatrists. Why would that be significantly different for PMHNPs?

[Mookiepsychnp]

Psychiatrists do not manage "psych meds only." Every psychiatrist I've worked with over the years (in inpatient settings) have done some primary care, i.e., dealing with the medical issues of the individuals on inpatient psychiatric units, and, in outpatient settings, they're responsible for the interaction of psych meds with whatever medical meds and issues the client may have, and to manage the medical side effects/problems related to psych medications they've prescribed. In my experience, that's considered part of the basic scope of practice of psychiatrists. Why would that be significantly different for PMHNPs?

I agree, in my facility the psychiatrist are responsible for some primary care such as H&Ps (mainly on weekends when medical consultant is off). If a patient is hypertensive they may start them on a antihypertensive or a sliding scale if BS are elevated and then refer them to the medical physician. The psych NPs at my facility have the same responsibility (especially if they are on call over night and a patient has a medical issue, they have to handle it).

[PsychiatricNP]

Hi myelin: I am a family PMHNP and I practice on an inpatient geropsych unit. I would not say that I practice primary care, but it is my responsibility to manage medical issues that might arise while the patient is on the unit. I routinely do H&Ps on the patients that are admitted to the unit. My medical management of the patient might include starting an insulin sliding scale, ordering films after a fall, treating a UTI, managing HTN, etc. I also know that I always have the support of the hospitalist service if I get into a situation that I need some help with (cardiac issues, etc.) or need to transfer the patient due to medical issues.

I do not feel qualified/competent to provide ongoing medical care for chronic or acute illness (outside of making referrals for co-mobidities that I identify when treating a patient) and am explicit with patients regarding this when I am working in outpatient settings. I routinely make referrals to the patient's PCP when I suspect that there is an underlying issue that is contributing to the patient's psychiatric presentation. I will order a TSH when working up a patient with depression, but refer this out if the result is abnormal. I know my ANP/FNP colleagues are much more skilled at handling these issues. While my state's BON is very vague about scope of practice, I prefer to err on the side of caution and stick with treating only psychiatric illness.

[myelin]

Thank you so much for the responses, everyone. It's been very useful and helped me put my friend's comments in context.

[nursetim, NP]

Funny you should mention this. We had a CNS that would alter my Rx for patients. I checked with my MD and he agreed that what I prescribed was appropriate, hey I make mistakes, not the third time. I always told my Pt.s " I don't prescribe psych meds, they don't prescribe HTN meds." Ha ha ha. Towards the end of my stay she would do it more and more often. Even on my MD's Pt.s. Her little choo choo went chugging around the corner. We started at the facility at the same time and she was fine then. I left and came back 6 months later and she had a crazy look in her eyes, I figured she had cracked listening to the psychosis and she caught some. Psych meds are hard enough. Stick with those. But help us ignorant wretches when we are stumped for what to put a new bipolar on that is on the $4 list at walmart.

[traumaRUs, MSN, APRN]

Amen nursetim.

[Psychcns]

I stick with what i know-the psych meds.ho