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Lemon Bars

Lemon Bars

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  1. Lemon Bars

    The avalanche of prior authorizations

    I have been working as an RN in a primary care clinic for nine months, and my experience with prior-authorization requirements is similar. This really highlights the problem with our third party payer system. Patients want unlimited access to expensive medications, specialists and imaging because they don't pay the cost of these things. Insurance companies make more money when they deny services, so they have thrown up a wall of red tape. Medical professionals are caught in the middle. Many times we don't even know that a medication wasn't covered until a patient calls weeks later saying that they never got the medication prescribed, and now they can't breathe, can't sleep, their blood pressure is out of control, or they end up in the hospital. I'm really surprised there aren't more lawsuits about this - but of course patients can't afford lawyers so they are just stuck, I guess. My clinic has a department for referrals and insurance issues. When I started nine months ago there were three administrative people in that department (none of them had formal nursing or healthcare training). One staff member in that department was fired, another left on maternity leave, another got hired and then got fired. So we have one full-time staff member digging through chart notes and trying to process referrals and prior authorizations. Our office manager sometimes helps, when she has time. I do peer-to-peer reviews with insurance companies, which is successful about 40% of the time once the request finally gets to that step, often after multiple denials and resubmissions. As you can imagine, we are several weeks behind on prior authorizations - and that is only counting the first submission of the request. Patients are waiting months or even more than a year to get an MRI, or they just never get one. To be fair, though, we have patients who refuse to do physical therapy, refuse to get labs done, no show at specialist appointments, and otherwise don't follow through with the steps required in the plan of care. This situation has affected my personal medical care as well (through a different medical clinic). A change of insurance caused the need for a prior authorization on one of my own personal medications. Despite multiple phone calls and a letter from me, that medical clinic was not capable of going through my records and providing my new insurance company with documentation that I had already tried the alternative medications suggested by my new insurance company. I now get by without this medication, but my quality of life was higher when I was on the medication. I have some ideas on how to improve the situation, but none of them are practical and easy to implement at the clinic level. One tremendous improvement would be to partially or fully integrate the computer systems of all medical facilities, pharmacies and insurance companies everywhere. I refuse to believe that this is impossible, though it may require new federal legislation to bring everyone to the table. Another improvement/solution might be integrated healthcare systems such as Kaiser Permanante, which mitigates the negative effect of our third party payer system. Or if we could put a pharmacy tech in every clinic, someone who could run medications through a payment system and come up with alternatives, that might be helpful. If insurance companies are going to continue to make things difficult, maybe insurance companies should be legally required to cover the cost of staffing for prior authorization departments. I am on the computer and phone most of the day dealing with medication refills, insurance issues, and managing those unbelievably time-consuming and stressful controlled substance prescription issues. I spend more time doing this than doing real nursing activities like triage, education and medical follow up. Honestly, I'm looking for another job, perhaps in home health or a specialty office. I can't go back to working in unsafe, understaffed hospitals. It is early in my nursing career and I'm seeing a long and rough road ahead, for both patients and medical professionals.
  2. Does anyone know if there are residential education programs, perhaps in the summertime, where an RN can enroll in a program lasting for multiple weeks and get a great many continuing education credits done all at once? There seem to be few local options for continuing education where I live in rural northern California. Plus I wouldn't mind escaping the summer heat for a few weeks... Thanks for any information!
  3. Lemon Bars

    Large numbers of prescriptions are being lost!

    Thanks folks. I am trying to document some of it but I'm so busy at work. I can't get any of the other nurses to track it. We are a small rural clinic and there are only two IT guys. Our office manager is our EHR software expert and she is totally overwhelmed with tasks every day. I'm told that we have no influence or local control over our EHR - we live with whatever decisions are made by big companies on the other side of the country.
  4. I'm a recent BSN graduate and I've been a RN at a primary care clinic for five months. We have a disappearing prescription problem and it seems to be getting worse. Through RN protocols, I am allowed to review charts send electronic prescription refills to pharmacies through our EHR system, which is Centricity. Every day patients are calling saying that pharmacies don't have the prescriptions - and when I call the local pharmacies the pharmacy staff say that no refill authorization was received. Schedule III-V controlled substances are not sent electronically, but are printed out, physically signed by a provider (MD, PA, NP) and then faxed to the pharmacy. Patients call because they can't get their prescription filled and the pharmacies deny they ever received the fax, even though our fax machine says it was transmitted successfully. Sometimes I call the pharmacy, speaking either with a pharmacy tech or a pharmacist, and I give a verbal authorization for a refill, carefully describing the medication, dose, instructions, quantity, refills, authorizing provider, NPI number, etc. And still some of these prescriptions go missing. By listening to snippets of conversation while on the phone with pharmacies, I have figured out that pharmacy staff are not typing the prescriptions into their computer system in real time during our conversation. Instead they are writing the information down on a form or perhaps a scrap of paper with the intent of entering it into their computer system later. Sometimes pharmacy staff fail to enter the number of refills into their system or they misplace the paper - which is sometimes found a day or two later when I call again to ask why the patient still cannot get the medication. Schedule II prescriptions are handwritten because, I was told, the controlled substance e-prescribing feature for Centricity is "clunky." Handwritten controlled substance prescriptions are a nightmare for many reasons, but what I'm most concerned about right now are missing electronic prescriptions, missing faxed prescriptions and missing verbally ordered prescriptions. This is a serious and apparently widespread problem reported by other nurses at our clinic. I have even experienced the phenomenon of lost prescriptions with my own personal medication about a year ago. Patients are angry and stressed out because they can't get their medications on time, can't get their diabetic supplies on time. Patients with infections are getting started two days late on their course of antibiotics. And our clinic nursing staff is wasting huge amounts of time reordering medications, re-faxing prescriptions, repeatedly calling pharmacies and waiting on hold for the pharmacist, and getting yelled at over the phone by patients who legitimately should have had their medication days or weeks ago. I cannot trust what I see in the medications module in a patient's chart because often it does not agree with what the pharmacy is saying or with what the patient is saying. I would like to find the sources of these problems and attempt to find solutions. It is our computer system? Is it our EHR software? Is it the computer system or software at the pharmacies? Does the fax machine not work properly? Or is it mostly human error at the pharmacies, physically losing track of faxes and papers and not copying the information correctly into their computer? What can we do about this? Should we print physical copies of prescriptions and give them, mail them or perhaps text them to patients so that the patients can show physical copies of the prescriptions to their pharmacies? What would it take to set up a HIPAA secure system for texting copies of prescriptions to patients? I am in California. Apologies for the long post. I'd be grateful for any advice on this. I spend one to three hours out of every workday on this nonsense.
  5. Lemon Bars

    Rapid response in the clinic

    I asked this same question not long ago. The nurse manager at the clinic explained to me that it was fine for employees to practice good teamwork and to operate informally as a sort of RRT, but that our clinic would not adopt an official RRT policy because if we have a policy it would be scrutinized and would be part of any inspections of our clinic. There would have to be an official record of who was on the RRT schedule for each day, etc. and we don't have enough staff at our small clinic for that sort of thing. I think my nurse manager was right; so long as there's at least one nurse who knows what to do and they recruit a couple of medical assistants to help when necessary, things seem to work out alright around here. We get few true emergencies anyway.
  6. Lemon Bars

    Urgent and emergent situations in the clinic

    I've worked at a rural family practice clinic for the last five months. For emergencies, we call 911 and get the patient ready for transport by ground or air ambulance. We have epi, nitro, and a few other emergency meds. We put patients on oxygen, do EKGs and occasionally start IVs. It is 30 minutes drive to the nearest hospital where we are. Since I have been here we have dealt with anaphylaxis from a wasp sting, several abnormal urgent heart rhythms, indigestion that presented as chest pain, and some elevated blood pressures that won't come down with meds. Any type of real emergency is sent to the hospital either by ambulance or sometimes by private car if the patient has a driver and refuses the ambulance transport. We also do minimal urgent care here, because our providers are generally booked up and we have no provider available for urgent care. We get people walking in asking for help, but if they are not established here as a patient they get sent to an urgent care clinic or a local emergency room. We will do some minor wound care, though. As the RN, I do triage for most of these situations, consulting a provider (MD, NP or PA) if they are available and if it's an urgent situation. I would say that, in my clinic, good triage skills are more important than good emergency medicine procedure skills. But if you work at a clinic that offers urgent care, you may do more wound care, etc. I hope that helps.
  7. Unfortunately you will only use a small fraction of what you learn in each class, both prerequisites and nursing school classes. Your analogy of throwing mud at a wall and hoping that some will stick is accurate. You will not need to know the difference between a tuberosity and a tubercle unless you specialize in orthopedics or something similar. However, if you study hard, you might learn enough about each topic to make a decision about what specialty area of nursing interests you most, and that may motivate you to independently learn more about that specialty area. You might also pick up enough information that, if you find yourself in an unfamiliar situation, you might remember enough to point yourself in the right direction when researching answers to questions that come up. I went through the prerequisites and a BSN program over the last five years. It seems clear to me that most teachers and administrators simply don't have the skill or the will to design classes that are more closely aligned with real working environments. Some teachers are too proud to spend time teaching practical skills and will only teach advanced concepts and philosophies. Consider yourself fortunate if you are taught by a professor who has the time, the energy, and the inspiration to seek out ways to help students connect class material to real life situations. P.S. I recommend considering LVN or ADN programs then bridging to the RN or BSN. The ADN students in my area get a lot more clinical time and learn more practical skills compared to students in my BSN program. We wrote more papers, though, if that's your thing...
  8. The staff at our clinic is wasting an incredible amount of time rerouting prescriptions from one pharmacy to another because patients suddenly decide they want to pick up their prescriptions from X pharmacy instead of their usual Y pharmacy. Also, our electronic health records system will only interface with Lab Corp, but many patients prefer to use Quest Labs. Has any company ever attempted to create a central database for lab orders, imaging orders and prescription orders, so that a patient can go to the lab/diagnostic center/pharmacy of their choice and then have that business access the physician's order from the central database?
  9. Lemon Bars

    I hate my current job and want to work in a hospital

    You might be able to make $16 an hour as a Telemetry Monitor Tech.
  10. Lemon Bars

    I want to be a Writer! Any tips?

    I've done a little research into working as a writer and my understanding is that making money as a writer is tough. You're competing against anyone in the world who can type and I've heard that only the very best and most well known writers actually make money. Look for writing gigs online and you'll see that they don't pay much. Journalism is collapsing financially because everything is online for free. Artificially intelligent computers are writing articles now. The standard advice for writers is to not bother with it as a career, unless you are so internally driven to write that you cannot give it up even when you desperately try to quit. Even then, the advice is: Don't quit your day job. But if you want to start a blog and give health advice, I think that's a wonderful idea. Just don't count on it making money unless you are incredibly talented, insanely dedicated, and unbelievably lucky.
  11. Lemon Bars

    Honesty on resume, now no job.

    I feel your pain from personal experience. I'm over 40 as well. Working in a fast-paced environment that is understaffed is a horrible way to learn a complex new career. I failed at my first two jobs as a new grad RN. One was a SNF and one was in a hospital. I have a job interview in two weeks at a rural critical access hospital and clinic which I've been lead to believe has a slower pace. If that doesn't work out I may apply to clinics, or try public health or school nursing. I work hard and hustle, but I really think employers are making unreasonable demands on the number of patients, the number of admits and discharges, the lack of nursing aides and back up nurses, etc. The hospital I worked at is short staffed every day, with patients held in the emergency room because they cannot be admitted into the hospital due to lack of RN staffing. But they won't change their work practices, even if it means leaving many patient rooms empty throughout the hospital.
  12. Lemon Bars

    Distractions & interruptions: ICU vs. other units?

    "Regardless of where you work, time management is one of the most important things to master. I have found (and most experienced nurses will agree) that one of the most helpful tools is a form that you create, of the tasks that you have to do everyday. You can look up templates on line, or create your own. But it entails sort of a chronological schedule of things you have to do. Scheduled meds, lab draws, dressing changes, checking sugars, etc. As you get report you fill out the pertinent stuff about your patient, and fill in the tasks. Check them off as you go. Meds and blood sugar checks are usually done at specific times, so you can put dressing changes and other stuff at less busy times. It is extremely difficult (if not impossible) to time manage in your head. Every unit has its distractions. Wait until your in ICU and the occlusion alarm starts going off every two seconds because the confused patient keeps bending their arm. Or the same confused patient tries to get out of bed every 5 minutes. There are quiet days, but you WILL go home hearing the call bells in your head all night long." I appreciate you taking the time to reply, nursy. However, I have already been operating using the types of schedules, checklists and notes that you are suggesting. Under no circumstances would I ever try to keep track of everything just in my head. Staying organized definitely helps and keeps me from forgetting many important tasks now that I understand the routine of how a nursing shift works. But even when I'm organized, I find that it takes some time to recover from interruptions and hard to be efficient in my work with distractions. Forgetting tasks is no longer my biggest issue; it's recovering from interruptions and getting work done despite distractions so that I can finish all of my tasks in a timely manner that is the biggest obstacle now.
  13. Lemon Bars

    Distractions & interruptions: ICU vs. other units?

    CampyCampRN you are describing experiences similar to mine. I think my brain must work in a similar way to how your brain works. Thank you for your comments.
  14. Lemon Bars

    Trying to find my niche in nursing

    Have you considered working in pre-op or post-op recovery rooms, in a cath lab, or other specialized units? Also, you have more than enough experience to apply for jobs in clinics, outpatient rehab facilities, outpatient surgery centers, home health agencies, case management agencies and many other jobs outside of hospitals. You have enough experience to apply for Director of Nursing jobs at skilled nursing facilities. Perhaps you need to expand your job search into new areas both in the types of facilities and geographically.
  15. I could use some advice, please. I am a new grad BSN who has had to resign from my first two nursing jobs. I have non-hyperactive Attention Deficit Disorder, so distracting environments and frequent interruptions kill my productivity and my sanity. I have been in the ICU three times with my preceptors. Each time that I arrived on the ICU from another unit, I felt a great sense of relief. It is quiet in the ICU. Each nurse has only one or two patients. Each patient has vital signs displayed on a monitor right in front of the nurse, and all necessary equipment is in the room, not scattered throughout the hallways like on the other floors. I know that the ICU and similar units are considered more advanced care, and I know that the patients are often unstable. I've been told that one must gain experience in other units before advancing to critical care, but I think that the ICU (or maybe an operating room) might be the only place in the hospital where I can focus and get my work done. I see that there are some new grad training programs that place new grads into the ICU setting. Does anyone have experience as a new grad in an ICU or experience precasting a new grad in an ICU setting? Thank you for any information or advice on this topic.
  16. Lemon Bars

    Fired from 1st nursing job

    I feel your pain. I am also a new grad BSN who was forced to resign from my first nursing job because I was not able to get up to speed quickly enough. Neither the manager nor my fellow nurses cut me much slack for being a new grad. Everybody wants everything done perfectly and lightning fast. I'm job searching again...
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