NP Practice Owners : Patient Care

Another Membership Practice

Jill Rollet — Mon, 14 Sep 2009 15:35:00 GMT

We've noticed just a couple of practices across the country that are turning to a so-called membership plan to help curtail costs for patients. The model requires patients to pay a flat rate monthly or annually and then covers office visits, routine tests and the like.

All the coverage I've seen of this model is careful to emphasize that this is not an insurance plan. If it were deemed insurance, a whole host of regulations would apply.

Here's a nice local news clip of a physician-owned practice in Utah that has implemented the membership model. What do you think? Would this be beneficial for your patients and practice? Would you risk the insurance-regulation implications?

Avoiding Burnout

Aaron Hartle — Mon, 15 Jun 2009 18:16:00 GMT

Seventeen months ago when I opened Pace Clinic I was excited to be out on my own. No more working for somebody, I could set my own hours, come and go as I please, and do my own thing. I have thoroughly enjoyed working for myself.

However, even though I no longer have (a) boss, I still work for now thousands of bosses (my clients). Sure, I can leave early when I want, come in late, or take an extended lunch break, but now that I have an established clinic in the community, my patients expect me to be at the clinic. I won't get fired for not being at work, but I may loose business, which leads to a loss of revenue, then maybe a loss of the clinic.

So, "just hire some help" you say, but that is much more difficult than it seems. Unless you have a lot of discretionary income, starting up a clinic is expensive. Many start out solo since to hire another practitioner can cost quite a bit of money.

In addition to this, most nurse practitioners in Utah where I work are not credentialed with insurance companies. They work for and bill under the doctor. So if I want to hire a practitioner, I have to get her credentialed, which takes several months to finally be on all the insurance panels.

Now what? I just do what many other NP's do, I work too much. I believe that anyone that works over 40 hours per week is overdoing it.

When I started the clinic I worked 64 hours a week just to keep things going. I am now down to about 50 hours per week and still think it is too much. Since I started, I have hit a couple of "burn-out" stages that I have had to make it through and have learned a couple of coping mechanisms. Here are some that helped.

First of all remember, anyone can do about anything for a little while. At first, it may simply take a lot of hours to get a clinic up and going, but remember, being overworked is probably necessary, and should be temporary. Focus on the long term benefits.
Exercise daily. That has been a good outlet for me and helps open my mind for the day. It also helps burn off pent-up frustration from the business, patients, etc.
Eat right. You need all the energy you can to start up a business. It is not easy.
Have fun. Turn on a radio in your office and dance for a minute after a stressful patient or watch a funny Youtube video then get back to work.
Have a lot of friends. I love spending time with friends, so I treat my patients like friends - well, sort of. We don't go hang out, but when they come in to the clinic, we chat, talk about exciting events since the last visit, etc. Due to time pressures, we don't do it for long, but the patient enjoys the feeling that I care about them, and I like the outlet to take my mind off work if only for two or three minutes.
Remember you spouse and kids. You probably can't take off work for every little thing, but if your child has a school play or a field trip, then go. If your spouse has a special appointment, take off and watch the kids so he or she can go. If you feel you are fulfilling your responsibilities in the home, you will feel better at work.
Finally, remember, you can't do it all. Ask for help, take one day at a time, remember your own limitations, and don't sell yourself short to your new practice.

Aaron Hartle, FNP
Owner of Pace Clinic (Springville, Utah) and Nucea Health & Fitness (Lindon, Utah)

Tips for Keeping Care Affordable

Joseph Marra — Wed, 18 Mar 2009 12:46:00 GMT

Many times in my day to day practice I run into patients who have financial instability. These patients have difficulty paying their daily bills, let alone medical ones.

Sometimes as a provider of care you need to be resourceful for your patients' sake. Remember that many pharmaceutical companies have programs that will give patients free samples for up to a year. You may suggest to your patient that they get online and print off the application and have it filled out, so as a provider you simply have to review and sign the document.

Also don't forget about the $4 dollar prescription plans that are becoming very popular at the larger pharmacies. Many antibiotics and anti-hypertensives etc., that are generic are really cheap right now.

It is interesting how expensive medicine has become. The first thing I look at when I pick up the chart is if they do or do not have medical insurance. This tailors the care received to some point.

I always give the patient the option of the alternative medication prior to writing the prescription. Many times it is a convenience of less frequency or a shorter length of course, however the end result is the same.

Also insurance dictates where they may or may not go. Some facilities such as PT only accept certain insurances. These are sad facts of daily practice but must be considered in order to give the patient the best possible care within their financial ability.

After practicing for several years I have gained a rapport with other modalities and kind of squeeze them in for a discounted price, or even for free. Once you explain the current situation to the prospective provider of care, sometimes they will even do it for free. I have done this many times myself.

Practicing with love and compassion toward your fellow man goes a long, long way. I have received many referrals from such patients, who have sent new patients that do have insurance, simply because of the compassion that you have shown. So it will all work itself out in the long run.

I try to practice with Peace, Love, and Laughter.

The Replacements

Gretchen Moen — Mon, 16 Mar 2009 19:42:00 GMT

This past week I had the pleasure of spending the day lecturing for one of the FNP programs in town. The experience was not a new one for me, but it was different in that I was "it" for the whole class day. I enjoyed myself very much, and my feedback has been positive to date. As I prepared for this posting I thought about this experience and how it pertains to business ownership.

Our clinic has a three-pronged mission: providing high quality health care services, serving as a resource to our community and promoting our profession. As one of two NP clinics in the area, we feel it is our duty to provide learning opportunities for health care professionals of the future.

Many of my colleagues are feeling the strain of financial pressures in their various practice settings. Instead of receiving straight salaries for work product, the trend is to compensate based on performance, which usually translates to sheer number of patients per day. Given the intense pressure to care for increasing numbers of patients, clinics and other health care systems are reducing or eliminating student opportunities. The argument is that students "take time" that could otherwise be spent seeing patients. Consequently there are fewer clinical sites available and far fewer students completing their training, especially in primary care.

Having control of my schedule and the general clinic schedule allows me the freedom to work students into the day without compromising patient care. Communication with the support staff as well as providers is essential. When the appointment time is flexible for the patient, we try to schedule visits to coincide with specific student requirements. Our patients are well aware of our educational advocacy and often express their excitement in "helping out" a budding health care professional.

What's in it for you?

Students challenge your process. They ask questions and want sound explanations for everything you do. Students force you to stay current with the latest research, evidence-based guidelines, practice trends and all the other aspects of practice one never has time to pursue. In a small practice, students are very valuable for filling the gaps with answering telephones or returning patient calls as the need arises. Students can also become future employees.

In some areas, clinics who train students are eligible for stipends through health care education funding.

I want to encourage you to design your practice to foster NP growth. Include student placement in your business model. Remember that you were once a student, too. Every single day I have a student, I learn something new or appreciate something special about my practice, my patients or myself. Today was another of those days.

Today one of our PNP students was evaluating two brothers for strep throat. English is not the family's first language. The eldest is 5 "and a half" years old, and the younger one is 4 years old. When they arrived I asked them why they came to visit me and the older brother said, "I have something in my throat that hurts but it's not strep throat." Throughout the visit the older brother continued his chatter; he couldn't wait to be 6 (years old) because then he would be King; he'd been to the dentist recently and described his experience by saying he didn't like "adult" dentists because they were mean and that "next time" he was going to see a "kid" dentist; he loved his brother and his brother copied him all the time but that he didn't want to copy his brother all the time; and he ended with: "my brother....we are a lot alike and like the same things but he is different because he is two shades lighter than me." The student was trying hard to stay focused and concentrate on the task at hand but couldn't help but laugh at this child's soliloquy... In the end, both the boys had strep throat!

The entire visit took 20 minutes, tops, but the lessons learned will last a lifetime.

Speed Up Word of Mouth

Aaron Hartle — Mon, 16 Feb 2009 22:04:00 GMT

I have a small clinic in Springville, Utah. I am opening a second clinic next month in a neighboring city. As we all could guess, my practice has grown mostly by "word-of-mouth" advertising. Since I am kind of a penny pincher, I spend very little on actual advertising and focus more on my patients spreading the word for me. It is free advertising, and it seems to work better than any ad I have had in the paper and has had a better financial rate of return that my quick TV appearance.

"Word-of-mouth" advertising, even though very successful, can be very slow. That can be a problem for the new practice owner who needs patients quickly to cover their new expenses. I have found a way to help speed up this type of advertising: I call my patients a few days to a week after they have come in to the clinic. I ask how they are doing and if whatever their presenting diagnosis is getting better. We then talk about what was prescribed, if anything, and what else can be done to help their condition if needed.

I try to personalize the call whenever I can to show the patient or their family that I care. If, for example, the son came in with a baseball injury, after finding out how he is doing, I might ask if he had a game since he was in the clinic, how he did, and if his team won. If you had a mother come in with a sinus infection, you might call back and when checking on her, show empathy about how tough it is to care for kids and keep the house tidy when sick.

The patients and their families are always appreciative that you actually care. They all seem to love the follow-up calls. One of my patients that I see on a fairly frequent basis actually asked during one visit why I hadn't called and checked up on her after the previous visit.

The follow-up calls show I care, but they also remind the patient about their good experience with the clinic, which will prompt them to talk about the clinic to their family, friends and neighbors.

A second way to speed up "word-of-mouth" advertising is to always show the patient you care about them. Be patient when they take an extra five minutes telling you about their brother's-sister's-son-in-law's strange mole. When they call your on-call number on a Saturday morning and apologize for doing so, tell them "it's OK, I have the number to call because I care about my patients." Furthermore, when appropriate, shake their hand, put your arm around their shoulders, give the kid's high five, etc.

Follow-up calls and befriending your patients can take extra time. However, if you are a new clinic owner, you will probably have more time than money until you get your patients established. Use your time wisely. Show patients that you care about them, and they will take care of you.

Holistic Approach

Joseph Marra — Thu, 05 Feb 2009 14:02:00 GMT

How many times have patients come to you for advice and after evaluation asked, "Do I have to take a pill? Isn't there something natural I can do?"

Well, I have listened to their cries and have decided to hire a hypnotherapist/Reiki Master. This individual has 12 years experience in hypnotherapy and at least 5 years in Reiki healing. I personally have become certified as a hypnotherapist and have gone through the Reiki training, levels I, II, and III.

Although I am limited in the time I can spend with alternative therapies due to my own busy case load, I am now educated in these alternative practices. My hypnotherapist is becoming very busy, especially with smoking cessation, stress reduction and weight management.

I truly believe that a combination of traditional medicine and alternative medicine is the wave of the future. This also gives your patients another option of care. Who better to evaluate the effectiveness of other modalities than a primary care practitioner?

Other helpful modalities may include massage therapy, herbal treatments and reflexology, to name a few. I don't believe that one modality is right for everyone but should simply be visited as a holistic approach towards caring for one's patients.

Does anyone else use alternative approaches in primary care?

The Interviewing Process

Joseph Marra — Wed, 14 Jan 2009 17:15:00 GMT

Well, I have been at my new office now for over a month, and yesterday's schedule had 38 people on! Yes, it is really taking off. I have advertised again, and I'm thankful for the responses. I will be interviewing three new prospects at the end of the week.

It really is difficult to see patients and manage a a busy practice at the same time. I plan on hiring some individuals to take up some of the slack. I still intend to practice on occasion; however, I am unable to continue this pace!

I have also just hired two ultrasound techs. One's specialty is in cardiovascular medicine, and the other is in general medicine. I will be hiring a women's health NP to care for my female population.

This venture has just exploded with opened doors and opportunities. If you believe in the premise that "Thought becomes reality" then, the sky is the limit. I feel strongly that medicine needs to transition into having several specialties under one roof. People enjoy convenience, and practitioners should welcome the continuity of care. I have also hired a hypnotherapist as well who also is a Reiki master. She is doing wonderful things for smoking cessation and stress management. Patients are always asking of "natural" ways of healing, therefore I offer these alternative services as well.

I will continue with the updates each time I blog for those who are interested.

Customer Service, Even When You Don't Feel Like It

Gretchen Moen — Tue, 16 Sep 2008 12:30:00 GMT

This past month has been a very busy month for us: school exams, shots, immigration physicals and paperwork, paperwork, paperwork. The old term "fix-me Friday" could be changed to "all-at-once August." In pediatrics this generally means get all the well exams, sport physicals, asthma evaluations, anxiety and depression evaluations, ADHD plans, etc., done before school starts and planned around the patient’s last vacation for the summer. Oh, and don’t forget, “I need everything on paper and faxed to the school, yesterday!”

All of a sudden you find you are less than amicable with the staff, they are less than excited to do one more kindergarten check up for you, and you wake in the morning wondering if you really want to go to work at all. That’s when I’d like to throw customer service out the window!

This month I thought it appropriate to address often-forgotten areas of customer service, beginning with the patient encounter.

The point of good customer service is to keep current customers and recruit new customers. Patients who are happy, tell their friends and so on. There are some simple ways to provide excellent customer service starting with the initial phone call. Always answer the telephone with a smile on your face —even if you don’t feel like smiling. If the telephone is answered by an unhappy person, that unhappiness is reflected in the tone of their voice or by the words that are used when communicating to the caller. All of us, at one time or another, have spoken on the telephone with someone who was obviously unhappy.You don’t need to see their face to know that they are bothered by your call and want to get off the telephone as soon as possible.

Patients do not need to feel your unhappiness when they are calling for appointments or questions. Anyone answering the telephone should sound like they have all the time in the word for the caller. Use the same techniques we use in the exam room: be attentive, get to the heart of the matter, repeat back what was said, and leave the door open for a return visit or return phone call. Remember, you never get a second chance for a good first impression.

Upon entering the clinic, the atmosphere should be inviting to patients and visitors. An inviting atmosphere does not mean cushy furniture, flat-screened televisions or a full coffee bar. Clinics with second-hand furniture, counter-top water coolers, fake fireplaces and hand me down magazines can be as inviting as the modern, state of the art, ergonomically designed clinics we see today. (Yeah, that’s us.)

What invites patients into the clinic, and keeps them coming back, is the way theyare greeted and processed throughout the visit. You may recall I mentioned having two focus groups during the planning phases of this clinic. One of the groups addressed the question: What would you like to see in the ideal clinic? Along with less paperwork, better appointment times and online scheduling, the primary characteristic participants desired in a clinic was feeling that the clinic actually wanted to help patients. Participants described encounters where they felt their clinic, and providers, were “bothered” by having to care for them or feeling like they were just another number or case.

It brought to mind my basic nursing classes on communication. We were instructed over and over again to refer to patients by their name — NOT the room number or reason for their visit (the ear in room 2, etc.). Develop an atmosphere where patients feel welcome and appreciated and are encouraged to return if they need your services in the future.

How you complete the patient visit can also impact the overall atmosphere of the clinic. How many times have we come upon a situation where there are two parties in conflict with each other? What does the atmosphere feel like to those who are not involved? Uncomfortable? You bet!

Patients and visitors walk past the reception desk when they enter and leave our clinic.Thanking them for their visit or just saying goodbye is a nice way to end their encounter with us. We are acutely aware of what people in the waiting area are able to hear and observe. If one patient or visitor is treated poorly, everyone else in the area will instantly become concerned about their own encounter. Think of the patient visit as having a guest in your home; you greet your guest with a smile when they arrive and say goodbye to them when they leave.

Keeping the schedule on time, getting accurate and complete information, assisting with further appointments or scheduling procedures, processing the paperwork and billing accurately are all necessary components of good customer service. Those are the areas we spend a lot of time perfecting, but I have found that the wayI treat my patients from the first time we meet until they walk out the door will impact their willingness to return or recommend my clinic to others far more than keeping my schedule on time.

Customer service has become a major focus in the business world. I like to call it treating your patients and visitors with courtesy and respect. Next month I will discuss ways we have tried to keep the work environment inviting for our employees.