Primary care in urgent care

[travelRN555]

I recently started what I thought was going to be my dream job- Working in an urgent care with another provider with me as the clinic is typically busy.

The reality is I’m often alone and see 35-50 patients in a day with limited support staff. Door to discharge target time is 1 hour.

Our medical director has recently made a point of training the new hires on a variety of topics, including ‘limited primary care’ to limit referrals

Long story short: the expectation is that we are to diagnose/treat/follow-up/manage new diabetes, hypertension, and lipids in the urgent care. Including giving insulin in the clinic and initiating regimens, dosing clonidine and starting them on one ore more antihypertensive. And ordering all the initial diagnostics.

My concerns are that the charting system is not set up for primary care documentation, we don’t have consistent schedules, and patients cannot schedule appointments. Labs are reviewed and dealt with by whomever is on the day that they result in the system and providers often work in multiple locations in the network.

I’m new to urgent care, so I’m not sure how other clinics work. Is this consistent with where others work- providing some primary care services-but not others, managing another provider’s primary care labs, etc?

[traumaRUs, MSN, APRN]

Geez this sounds like a nightmare. How are these pts followed after their visit to the urgent care?

[travelRN555]

They are to come back every 2-3 days for blood pressure monitoring and adjustments and same for blood sugars and then every 2 weeks for fructosamine levels - which I had never heard of before our lecture. But they could, and will most likely, see a different provider each time, with yet another signing off on the lab results

[traumaRUs, MSN, APRN]

Wow....is this because your population has no insurance? I live in central IL and our urgent care clinics are just urgent care. They will refill a med you are already on or start one anti-hypertensive but then you are to see your PCP.

This sounds like very fractured care....

[travelRN555]

No, most have insurance, they just aren’t set up with primary providers.

These diagnoses would be made from incidental findings during an urgent care visit- ie they came in for bronchitis, but have a high blood pressure reading —>check CMP because of the blood pressure—> they are hyperglycemic —>check a1c—> and on and on

[Power2020]

Hello,

I'm sorry to hear your dream job did not turn out the way it should've been! It sounds very disorganized. Firstly, urgent care should only be urgent care...unfortunately I know urgent care facilities do this...and it's hard because the continuity of care becomes fragmented...mainly because when you are working 12 hrs...!!!

The way you mention they are doing primary care based on incidental findings is odd. Primary care visits are really supposed to be 30 minute visits and if you are seeing THAT many patients a day that can get ridiculous and burn out!

I am in urgent care and we do some primary care but it is very basic...diabetes/hypertension/hyperlipidemia - but not in depth workups...It's pretty easy (but I have a strong primary care background) so it looks easy to me...if it was my first job it would be nerve racking and difficult.

I hope your pay is good for all this drama...but remember grass is not always greener on the other side.

What ive seen from family practice is 8-5 is like a 8-600, with 4-6 hours of charting a week/plus call....the rate goes down to $40/hr roughly with all the work....a family practice clinic is a true burnout

[djmatte, ADN, MSN, RN, NP]

23 minutes ago, Power2020 said:

Hello,

I'm sorry to hear your dream job did not turn out the way it should've been! It sounds very disorganized. Firstly, urgent care should only be urgent care...unfortunately I know urgent care facilities do this...and it's hard because the continuity of care becomes fragmented...mainly because when you are working 12 hrs...!!!

The way you mention they are doing primary care based on incidental findings is odd. Primary care visits are really supposed to be 30 minute visits and if you are seeing THAT many patients a day that can get ridiculous and burn out!

I am in urgent care and we do some primary care but it is very basic...diabetes/hypertension/hyperlipidemia - but not in depth workups...It's pretty easy (but I have a strong primary care background) so it looks easy to me...if it was my first job it would be nerve racking and difficult.

I hope your pay is good for all this drama...but remember grass is not always greener on the other side.

What ive seen from family practice is 8-5 is like a 8-600, with 4-6 hours of charting a week/plus call....the rate goes down to $40/hr roughly with all the work....a family practice clinic is a true burnout

Probably depends on the clinic. Mines 9-5 but some work other hours for patient accommodating. I might work an hour or two on the weekend closing charts that I slacked on during the week, but hardly a thing. And that's with a patient load of 18 to 22 a day. Lots of it comes down to charting efficiency and getting to a point that you are seeing more chronic follow-up patients.

I think there's value to combining primary care with urgent if you're set up for it. You need staff dedicated to the individual areas and you need a charting system that can do both. But it sadly sounds like the op location isn't up to the task. They are expecting to start patients on medications for chronic illness (some of which needs serious monitoring/follow up) with no capacity to schedule and the hope that patient will return at designated intervals? Imo it sounds more like they are trying to add on charges as they go down a line of abnormalities under the guise of helping. It's like a car mechanic who keeps finding something new wrong and expects you to pay for years of poor upkeep in a few short visits. It's disingenuous service and borderline highway robbery.

[traumaRUs, MSN, APRN]

I just keep coming back (and understand I'm in nephrology) that if you trying to manage HTN/DM, etc., in a fragmented way, you are missing the opportunity to refer to HTN specialist/nephr practice. This seems a fast way to get to chronic kidney disease to me.....

[travelRN555]

Djmatte- I think you are absolutely right about the money..... we were also told we have to check in EVERYONE, even if we know we can’t treat them in the clinic and then bill them for a visit even though we are sending them to the ER- because ‘it’s the law’. I worked in the ER and am very familiar with EMTALA- but as far as I knew it only applied to emergency departments?? And what law says that if a patient is even greeted by a provider we must legally bill them for services?

For example our policy is age 2 and up- but a stable 6 month old with a fever comes in- or a patient with an open fracture - things that you can immediately tell cannot be treated and safely sent along to the appropriate place- are to be checked in, wait to see the provider, and then told we don’t have the resources to treat them.

Is this the same in your urgent care?

[djmatte, ADN, MSN, RN, NP]

I don't work in urgent care. Just primary. Though we do see acute cases, but probably at the numbers uc does.

[Ddestiny, BSN, RN]

That sounds really frustrating. When I started out in nursing I worked in a primary care office that also owned 2 urgent care offices in the same town. Providers could see information between both different systems so if one of our primary care patients had an issue over the weekend, we could be aware of everything. The urgent care office could also see all of the pertinent medical history. It was a really nice system and it makes me wonder if there is something similar in your area?

[travelRN555]

This is just solely an urgent care system with an EHR designed specifically for urgent care. Most of the time the MAs don’t enter the proper history and there has been more than one occasision a provider has prescribed a medication that the patient is allergic to because the MA didn’t bother to put in the allergy list and simply clicked ‘no allergies’, despite the patient having written the information on their forms.