Goatie

This is a reply for Susan D.H. I admire you for taking a break from nursing to take care of your family. Kids grow up way to soon; before you know it, they are teens and off to college. I have LTC experience as an NP. I am a geriatric NP, so I love this population. Its a whole different world than primary care, thus yes it will be a steep learning curve. There are many challenges. When you work in LTC, you will have a mixture of custodial and rehab (skilled) patients. Think of the nursing home as your mini-hospital; staff nurses will be calling you for orders and you're "the doctor". You will have a panel of patients that you are in charge of managing. At various times, you will have to "skill" your custodial patients who get sick (e.g. Convert for custodial status to skilled status, when you give IV fluids, order more than 2 days of PT, etc. Certain procedures like IV makes someone "skilled" and no longer custodial). Or you will have short term admissions only (SNFs love those $$$). There may be intense pressure to keep patients from being admitted to the hospital, pressure to limit "skilled" days (they are expensive compared custodial days). You will many times have to speak with family about hospice enrollment (expect some No's). Dont start treatments without getting the OK from the DPOHC (at least a notification not just permission, e.g. Aricept). Invest in the app Epocrates to get the latest meds, med doses, treatments, labs, dx definitions. Get the monthly subscription and not the free app (which is bare bones). There are other apps like Prescribers Letter. There are SNF politics and drama, but hopefully you will be removed enough from those, because you are in and out. The good new is: If you work for an insurance group or company- they will provide a mentoring/partnering physician; he/she should be available for all kinds of difficult medical cases, as well as joint visits/rounding. The company will also have guidelines, standardized procedures, resources on-line, education classes. You will/should have an NP manager; you can approach him/her for any operational/admin/charting problems, and also issues you may want to discuss before calling your doctor. You will have other NP colleagues to *** and moan with, and there will be monthly meetings/social gatherings. There will also be specialists that patients already have, so you are not the end all, be all. If you are hired by a physician in private practice/solo, then this may be more of a challenge because you may not have all the support that a company provides that has an army of NP's. I wish you the best of luck.

Nursing@USC is accredited by the Western Association of Schools and Colleges (WASC) and pursuing initial accreditation from the Commission on Collegiate Nursing Education (CCNE). ... Request information to learn more about Nursing@USC. Yes very expensive indeed. Sorry for this duplicate response.

Sorry, this is a duplicate response

For an old dinosaur like me, HRA's are great in terms of flexibility and pay. You are often paid per case, not per hour. So I do 3 assessments a day (each lasting 1-2 hours depending on complexity and needing a language translator), and then pick up the kids from school. But if I wanted to, I could work up to 6 cases a day, 7 days a week, including evenings. My company is great with IT support and management, on-going education, and team meetings. Of course the driving is the disadvantage, but the company tries their very best to bundle the appts within the same area... As a new grad, this would not be my first choice: I would want to exercise my dx and prescribing "muscles". With HRA's, it is all about health promotion and disease prevention. Lots of educating, which is my favorite. You will make referrals, call the PCP if urgent, even call 911 if emergent. You have to be very thorough (OCD-like) with the forms, and be very good with diagnosing and coding. Its not for everyone, but it is a job if you don't want to a 40+ hour week clinic/snf job.

I believe hospitalist NPs and anesthetists make the most bucks. Psyc NP's too, coz not everyone has the constitution for mental health problems/illnesses. If you work in snf's, this is a high paying gig, because pts can be so sick in the snfs (just like acute and sub-acute type problems because the HMO's wont transfer them). When accepting a job, look at all the benefits including 401K. Some companies are extremely generous with their matching (Ive had a job that did 100% matching if you put in 6%). Another company paid 50% matching of whatever you put in after 3%. I wouldn't go for under $60/hour now but I'm an experienced dinosaur.

OMG, I remember a job where there was no end. Just because the time has ended seeing pts face to face, you have to deal with all the tasks as stated above, plus doing admin emails, calling families/snf staff, etc. Not to mention being on-call at night and weekends, on a rotation basis with the other NPs/MDs. And it is true: I used to do charts during the time when most people are asleep. I even worked during vacation, and I looked really pathetic doing charts by the hotel pool. Just like any job, there are pros and cons. Being per a diem or part-time NP is the best position you could be when there are big family commitments such as children or ill/elderly parents. If you could find a full-time job yet can have manageable work-life balance, then more power to you. Goodluck.

Hello! RN's cannot do HRA's- You must be an NP, PA, or MD because you are diagnosing and the health care companies are using these diagnoses very heavily for Medicare reimbursement. And of course you need to be in advanced practice to bill the feds. It is a lengthy visit due to needing to gather so much data because its an annual visit. You will be trained on what to gather- Ive had two HRA jobs already and theyre pretty much all standard nationally. There are pros and cons to this job. The PRO's: Super flexible, specially if you are part-time or per diem. Its great for NP's with families or who just need additional income. I usually just schedule 3 patients a day and I am done to pick up the kids at school. Meeting nice patients and families- I love to look at gardens, and they always like to take me around their properties to show off. I love to educate, and we all know so many things happen in the home they aren't telling the office providers which you can catch (specially safety issues). When you have a great scheduling department, this is like gold. The CONS: It tends to be seasonal: What I mean is, you will sometimes have NO pts for weeks or months on end, while the company tries to renegotiate contracts with the health plan. So, many of my colleagues have 2nd jobs. Those who do full-time/salaried are then asked to do other admin types of duties, or are asked to travel over-night to other cities. The drive can be horrendous specially in urban areas, and the more the pt appts dwindle, the farther you are sent. Visits can get really long- I can do a very thorough job for an hour (maybe 1.25 hrs d/t labs) but it becomes a 1.5 to 2 hour visit for pts who need your translation service. Therefore, in my mind (I make less money per hour because we are paid per case/visit). It behooves you to work faster but thoroughly. And of course, you will meet many types of characters in their homes (I haven't quite met a hoarder yet), and there are not so swanky neighborhoods (thankfully, I haven't met danger). Working with bad schedulers can be a nightmare (not my current employer). I WOULD NOT DO THIS if I was a NEW GRAD. Its just me, but as a new grad I would want to be somewhere where I can get the most experience diagnosing and treating, and this isn't it. It is great if you want a more kick-back role as an NP. Don't get me wrong, it is still a job that needs you to be OCD with "crossing every T and dotting every I". You need to capture every possible dx you can get, and having matching meds/PE/labs/hx to prove the dxs (otherwise you wont hear the end of it from QI and your NP manager). Ive been an NP for 20 yrs so this is perfect for me.

Its so awesome to hear Snf/ltc NP's who like what they do. More power and best regards. For me, I did not like it and I swear I will not do it again. I used to work for a large HMO. I had a panel I had to take care of which was a mixture of long term care and skilled pts. First, there are pros and cons. The pros: You cant beat the autonomy and respect (once earned). It is fulfilling to know you are treating people, helping families, and helping the staff nurses too (many of them are very nice and caring). You are being "productive" for the company too, coding the correct diagnoses for the max amount of medicare/medical dollars (ethically and truthfully of course). You have the peace of mind that the staff are there for any problems. Working with a supportive boss and MD are plusses too. The cons: Working in a snf is like working in an acute hospital, and I dont like acute. I had to know when was the time to admit pts to the ER/hospital (always discouraged if possible); referring to specialists was highly discouraged; I had to know when to "skill" patients (admit to skilled days). And you are the provider ordering treatments like IV fluids, wound tx, P.T. orders, etc). MD is there for support, but you are running the show; had to know when to discharge from skilled days (as to not displease the HMO, the snf, and the families/pts). The admission and d/c from skilled days were practically an art form: You didn't want to piss off the HMO by having the pt stay skilled too long, but many times they demanded pts be discharged even though I didn't think pts were ready. The snf always fought against d/c from skilled days because they wanted the revenue. Sometimes, they went behind our backs and told families to contest (or "appeal") the d/c, gave them the 3rd-party governing body's tele number to call for this (getting too many appeals per year is bad for the HMO, and for the provider). Then you have snf's who want to discharge LTC pts out of the facility altogether in order to focus their business of mostly rehab/skilled pts because these generate more money for the snf owners. Then of course, there are many bad characters who work at the snf, eg some nurses, DONs, owners). You will also see the futility of life, pts on vents or are being kept alive with no hope of recovery because they didn't sign an advance directive, or I swear someone (like family) was benefitting financially by keeping them alive (sorry, I'm jaded). I believe it takes a special NP to do this work; I'm sorry I am not one of them even though I wanted it badly to work out. I just dont have the patience or constitution for it, I got too stressed. My story seems to be a downer, but it sounds like many NPs on this blog like what they do.

Sorry to hear that. Maybe its all in your demeanor? I mean, some patients may think you are too loud and "overly friendly" (which helps to calm people down during an emergency when you were an EMT, but may translate as intimidating and unprofessional in a small office exam room. I'm just speculating. I agree with the other post, like do some role-playing or do an exam on a colleague and get some feedback. I agree with the other post that by the time pts reach us, they could have been waiting a while so they are watching every single hand gesture and hear every inflection of our voice, and feel every slight touch of our hands. During clinical, I remember a "live" patient/model asking why someone's hand was laying on her thigh when it was unnecessary (during my classmate's exam). I know its tough, but make this a learning opportunity to improve upon your exam and bedside skills. Good luck.

There is a huge demand for Psyc NP's. With that being said, there is a large demand because these jobs are hard to fill for the employer- not everyone has a stomach or the constitution for psyc. Personally for me, I found it too challenging. With adult pts, you will deal with schizophrenics, bipolar depression, drug addiction, homelessness, non-compliance, etc. Mostly med and lab management, taking calls from families/nsg staff. Also dealing a lot with the DPAHC or public guardians. I had a pt once was schizophenic and bipolar, and was on cocaine, mj, and alcohol (I didn't mention names, so I'm ok HIPAA-wise). I had to deal with snf's who did not want to take psyc pts (unless you gave them coveted "skilled days" first). Ive had snf's who did their best to d/c stable psyc pts, even if it meant they went somewhere unsafe. Ive had to deal with psyc hospitals who would not admit pts, because they were not unstable enough... On the bright side, it is a great satisfaction when you have stable pts w/ good quality of life, and you are a part of making this happen. So, you really have to love (or really like) what you do. No amount of money would entice me into being a psyc NP, but that's just me.

I looked up the H1 b Visa now... It looks like the reason the admin said 'mandatory' $130K salary is to discourage companies from hiring foreign NP's (or other highly trained foreign workers) and instead find U.S. trained or U.S. based workers. This makes sense. I was puzzled before because $130K as a starting NP salary is quite high, or uncommon. So yes, this is a dilemma for you if you need visa sponsorship- they may pass you up due to this requirement. Maybe work for a job without asking for sponsorship, just to gain experience? I don't know if this is possible for you. Or you could apply to just see what happens, and who knows, someone may hire you. Maybe if you worked in an area that is underserved, you may have a better chance of being hired? Good luck to you and let us know what happens.

USC places students in clinicals; you don't have to go around time searching for your own clinical hours (as I know other universities require you to do, and is a shame. If a school will charge a lot for tuition, they should place at clinical settings).

That's interesting. Ive never heard of this. Ive never heard of any salary being 'mandatory' at all at 130K. I mean Ive been an NP for 20 years, and the NPs who make above $120K usually work as anesthetists, OB, specialties, and usually work very hard with long hours. When I search for jobs, they usually only pay highly experienced NPs the most (>$60/hour). I will look into this and see what you are talking about just for my own curiosity, but $130K is a lot to ask for for a new NP (unless you are going to work for a very complex set of patients, eg. skilled nursing).

CONGRATS!!! I had to take the ANCC Gero test twice coz I didn't seriously study the first time around. I definitely would suggest ordering study guides/CD's for anyone who wants to take the test. And I also stayed at a nearby hotel so I didn't have to commute to the testing center. Now the ANCC Gerontological NP certification is not around anymore, but the equivalent Adult Cert is good too. Now, your job is to maintain certification every 5 years. Make sure you turn in your re-application forms 6 months before expiration (or whenever they say), otherwise you take the test again. I just make sure I have all 150 units of CEU's q 5 years they require, and now I'm on my 15th year as a ANCC GNP-BC (There are other pathways for reapplication, not just CEU's but I'm not published nor do I precept at this time).