Psychiatry question - Must I provide Therapy too?

[PMHNP Man]

Obligatory anecdote:

I currently work in an environment in which all the psych staff tend to spend more time with patients engaged in "supportive counseling" or other therapeutic dialogue. Despite being at the cusp of burn out, I really don't wish to do this. I only want to assess symptoms and medication efficacy and frankly feel that's all I'm good at and have a fairly low emotional intelligence of my own.

Question:

How many of you are brazen enough to say something akin to "How about we just talk about your medication today?"

Passive resistance to responses:

At my last job I was ok with this, but it was a different time/place/population and until the mortgage is paid I'm hooked.

[Oldmahubbard]

1 hour ago, ARND said:

Hey All,

I am currently a PMHNP student....more than halfway through as I am in a post masters program. I can believe I found this topic! I have been so annoyed with my programming in that they’re focusing on all therapy. Disclaimer: I am an advocate for therapy. It is just that I do not want to be a therapist. What I’d like to do is therapeutically communicate with patients and manage them medically with drugs and prescribing them therapy.

My clinical experience has been nothing but this! Yet, school is focusing on Freud and Skinner, CBT,DBT, and motivational interviewing (which I like and think is effective to use in short office visits). Maybe you should look into a consultation liaison role. This is my plan to see patients inpatient and move on to the next one . Where I previously worked we had no outpatient clinic in psychiatry so we referred out to the community mental health clinic or if the patient had a provider, back to them. It’s crazy how the ANCC is attempting to make this role like a lcsw rather a psychiatrist when the need is exactly as a provider! I understand your frustration. I hope it works out for you.

My advice is to maximize self preparation on the drugs, because that is what any employer will expect from you.

[verene, MSN]

On 8/12/2019 at 8:37 PM, PMHNP Man said:

Yeah, I'm with the VA. ... Being a highly politicized organization with therapy-oriented bosses makes it difficult to have people in and out quickly and focus on pharmacotherapy. 

How long are your appointments for follow-up? And what code are you typically billing alongside the 90833? Short medication management appointments usually don't leave a lot of time for therapy beyond therapeutic communication and some supportive listening/validation and maybe light motivational interviewing, so I find it odd that your manager would expect you to be doing a lot of therapy? Unless they are scheduling longer appointments - in which case give them a budget breakdown of shorter but higher number of med appointments vs therapy appointments in terms of reimbursement. Or is this expectation coming from a lack of therapists in the organization?

[PMHNP Man, MSN, APRN, NP]

Just now, verene said:

How long are your appointments for follow-up? And what code are you typically billing alongside the 90833? Short medication management appointments usually don't leave a lot of time for therapy beyond therapeutic communication and some supportive listening/validation and maybe light motivational interviewing, so I find it odd that your manager would expect you to be doing a lot of therapy? Unless they are scheduling longer appointments - in which case give them a budget breakdown of shorter but higher number of med appointments vs therapy appointments in terms of reimbursement. Or is this expectation coming from a lack of therapists in the organization?

30 minutes on the med checks with a 99213 typically. Yeah, it's the desired outcome of each visit with the the therapeutic dialogue and psychoed it's a doable deal. In a revenue generating capacity is favor it, but then in that instance I'd rather do 4-5 med checks per hour and no therapy. I support therapy and order it everyday, but I couldn't care beans about anything not symptom or med related in my professional capacity.

[Oldmahubbard]

I've been in this business for nearly 20 years. Most people are looking for a magic pill, or they are waiting for the world to change.

I personally practice ACT, but psychotherapy is mostly a crock, sorry.

[umbdude, MSN, APRN]

17 hours ago, Oldmahubbard said:

I've been in this business for nearly 20 years. Most people are looking for a magic pill, or they are waiting for the world to change.

I personally practice ACT, but psychotherapy is mostly a crock, sorry.

Psychotherapy works only if the individual is committed, otherwise it's of little use. Most of the patients I see now (SMI, dual) have little interest in therapy and they'd much rather take meds even if it's for the placebo effect.

[verene, MSN]

20 hours ago, PMHNP Man said:

30 minutes on the med checks with a 99213 typically. Yeah, it's the desired outcome of each visit with the the therapeutic dialogue and psychoed it's a doable deal. In a revenue generating capacity is favor it, but then in that instance I'd rather do 4-5 med checks per hour and no therapy. I support therapy and order it everyday, but I couldn't care beans about anything not symptom or med related in my professional capacity.

Propose to management shortening to 20 minutes and 3 appts an hour? Alternatively really structured assessments can cut down on some of the therapy time?

I'm surprised that most of the visits are 99213 as during my clinicals I was at a VA clinic and >50% of our patients were 99214 by complexity so we were doing a lot more assessment and a lot less therapy.

[PMHNP Man, MSN, APRN, NP]

Just now, verene said:

Propose to management shortening to 20 minutes and 3 appts an hour? Alternatively really structured assessments can cut down on some of the therapy time?

I'm surprised that most of the visits are 99213 as during my clinicals I was at a VA clinic and >50% of our patients were 99214 by complexity so we were doing a lot more assessment and a lot less therapy.

Yeah, it's an odd place. I do a lot of what I'd code 99214 in any other setting, but here they're fixated on the number of diagnoses you treat at each visit and don't like any referen to diagnoses you didn't address die to the quality metrics.

I don't want more appointments per hour because I'm not going to get paid more.

[verene, MSN]

33 minutes ago, PMHNP Man said:

Yeah, it's an odd place. I do a lot of what I'd code 99214 in any other setting, but here they're fixated on the number of diagnoses you treat at each visit and don't like any referen to diagnoses you didn't address die to the quality metrics.

I don't want more appointments per hour because I'm not going to get paid more.

Sounds like it is an odd place, and that policy doesn't make much sense to me.

My clinical experience at the VA was formative - I learned a huge amount and can now document insanely fast, but also came to the conclusion working there would probably eat me alive and I'd burn out in less than 3 years if I accepted a position. They seem to place a unsustainable workload on their outpatient PMHNPs.

Could you transfer to inpatient? or ED consult? I shadowed an ED consult PMHNP at the VA and her job was pretty focused on assessment, and a much lighter load than the outpatient providers carried.

[PMHNP Man, MSN, APRN, NP]

15 minutes ago, verene said:

Sounds like it is an odd place, and that policy doesn't make much sense to me.

My clinical experience at the VA was formative - I learned a huge amount and can now document insanely fast, but also came to the conclusion working there would probably eat me alive and I'd burn out in less than 3 years if I accepted a position. They seem to place a unsustainable workload on their outpatient PMHNPs.

Could you transfer to inpatient? or ED consult? I shadowed an ED consult PMHNP at the VA and her job was pretty focused on assessment, and a much lighter load than the outpatient providers carried.

I actually feel like the load is rather light, quantitatively. Our max is 12/day if they're all med checks. I used to schedule that over a 3-4 hour window, but more rapid work was heavily incentived and lucrative. I miss that dearly. I document rapidly and type while the patient is talking. I couldn't handle it any other way. Qualitatively, however, the burden for each visit is the associated fluff each visit requires, e.g. assessments, med reconciliations, suicide screenings, onerous coding processes, etc. I'd love to be a federal retiree, but I'm hard pressed to stay another year much less 20. It has sort of sucked the pleasure and enthusiasm from my marrow. I enjoy the higher functioning population quite a bit, but the bureaucratic antagonism outweighs that. I just don't know what I want to do at this point. I've come to the end of my five year plan and don't know what to do to formulate a new one.

[Oldmahubbard]

I cannot picture anyone making an actual living doing 12 med checks a day.
Nope.

For one thing, it wouldn't take 8 hours. Or even close.

[PMHNP Man, MSN, APRN, NP]

24 minutes ago, Oldmahubbard said:

I cannot picture anyone making an actual living doing 12 med checks a day.
Nope.

For one thing, it wouldn't take 8 hours. Or even close.

Hence their current dilemma, lol.

In a 40 hour work week only 29.5 hours has to be clinical.

[djmatte, ADN, MSN, RN, NP]

On 8/16/2019 at 7:01 PM, PMHNP Man said:

Hence their current dilemma, lol.

In a 40 hour work week only 29.5 hours has to be clinical.

And sadly we wonder why veterans don't get the access they need. I loved my time working at the VA and got to do a lot on my own setting up their pain clinic. I still go there for care, but it is definitely a cush job insulated by red tape and slow change. Not for the overachievers sadly. And God help you push for more patients. That will be met by resistance by those thrilled about that chill workday.