NP Practice Owners : Professional Standards

NP Medical Home/Health Care Homes

Gretchen Moen — Thu, 08 Oct 2009 13:23:00 GMT

It has been a very busy fall for ECFC. In addition to general patient care and all the day-to-day administrative issues, we are faced with another task. The state of MN has mandated that all recipients of state-sponsored health insurance have access to and are members of a state-certified Health Care Home.

Eagan Child and Family Care is one of 15 recipients of a grant to attend the Institute or Family Centered Care Intensive Training session at the end of this month, in preparation for meeting the requirements to become a certified health care home. Our plan is to meet these requirements over the next 90 days. We are fortunate to have a DNP student who is helping us with this process as part of her doctoral project.

There are a number of agencies that offer some type of Medical Home or Health Care Home certification. Along with the State of MN, The National Committee for Quality Assurance (NCQA), The Joint Commission Accreditation on Ambulatory Care and Hospitals, Bureau of Primary Care/Health Resources and Service Administration, Medicare CMS Demonstration, and other state agencies. Some of these groups have fees associated with the process.

Criteria for certification for Health Care Home/Medical Home are slightly different, depending on which agency is involved, but there the basic requirements to measure performance are in these critical areas: patient access and communication, patient tracking and registry functions, care management, patient self-management, test tracking, referral tracking, performance reporting and improvement measures, electronic prescribing and advanced electronic communications. Within each of these areas there are components that are considered key and some that are highly recommended. Minnesota is developing a process to reimburse providers for care coordination services in an effort to defray the actual and potential costs of implementing and sustaining health care home services.

Care coordination, collaboration, patient centered care...these are the foundations of NP practice. I know the way we deliver our services is not going to change, more so the way we track and monitor the delivery of those services. I will keep you posted on our progress!

Swine Flu Disaster!

Gretchen Moen — Wed, 06 May 2009 20:09:00 GMT

Do you have your disaster plan ready?? The avian flu spurred organizations to evaluate their disaster plans and to revise or add provisions in response to a national biohazard or infectious disease disaster.

Our county health department has been holding meetings for care providers to assist them in developing individual disaster plans as well as plans for working together in the event of a health care crisis or national disaster. Well, the H1N1 flu situation kicked it into high gear these past two weeks and some of us were not adequately prepared.

I like to think I am on top of most things but, alas, there are times when I drop the ball... What would you need to consider when you develop your disaster plan? One disadvantage we have is that the HVAC for the building is all interconnected. Each suite has their own control panel but the duct work and pipes all connect at some point in the ceiling and basement. The dentist offices would close but our patients would need to have access to us. What to do?

What kind of patients would you be able to help during a disaster? Our office would not be able to care for highly contaminated or infectious individuals but we could be a vaccination station or call center.
Who would man the office? Do you or your staff have children at home? What would happen if the schools or day cares were closed? Would your staff be willing to work in a potentially hazardous situation? How would you make that decision?
What type of personal protective gear do you need? Can you afford to buy the necessary gear?
What would happen to your equipment, supplies and records? Storage of HIPPA-sensitive material? Storage of temperature sensitive medications or vaccines?
What about simple "disasters": power out for more that 4 hours, phones out, computers down, locked out, patient or staff safety... we could go on and on.

Oh the advantage of having a smaller clinic! The health department sent e-mails with sample protocols for anyone who did not have a plan in place. We modified them slightly and had them ready within a couple of hours. The county nurse stopped in and issued N95 masks, instructed the staff, and reviewed our protocols. There were no committees to approve or disapprove of the written plan, no need for a timed roll out and very little lost time for education and implementation.

There are days I long to hire a person who can do the OSHA, BLS, HIPPA, RED FLAG, SAFETY, COLA and all the plans, rules and education requirements we need to review every year..... someday. For now, we are ready for H1N1, maybe H1N2.

Don't Get Sued!

Aaron Hartle — Wed, 15 Apr 2009 11:43:00 GMT

During my 2 years attending graduate school in the University of Utah Family Nurse Practitioner program I remember hearing the phrase about being sued, "it's not a matter of IF but WHEN." This has always worried me, especially now that I am a business owner.

I have good medical liability insurance, but the thought of being sued is scary. A suit can lead to loss of income, increased stress, lack of sleep, and higher insurance rates, among many other worries. In the 4 years of being a nurse practitioner, I have never been sued (knock on wood). The following is a list I try to adhere to, which helps reduce the chances of getting sued.

Be Nice. Very few people sue their friends. This doesn't mean you have to buddy up with each of your patients, but just be kind and show compassion. Patients know when you are in a hurry with them, annoyed at something, or treating them like a paycheck. If you show them that you genuinely care about them, they will feel it.
Be Honest. If you make a mistake, promptly admit it. We are human and will make mistakes. If you lie to a patient or try to cover something up, they can tell. However, if you always tell the truth, they will understand.
Be Open. Sometimes I'll tell a patient, "I don't know" or "I'm not sure and need some help on this." Don't try to be a specialist in areas you really aren't.
Be a Team Player. When you are unsure of a diagnosis or procedure, don't be afraid to ask help. Have a network of other practitioners to call on if you have a question. Don't be afraid to call and consult with a specialist. Hire a physician consultant to refer patients to. Never get caught doing things you are unsure doing. If you feel nervous treating a condition, doing a procedure, or prescribing a certain medication, then don't. Refer the patient or consult with someone until you feel proficient at the task. Several practitioners have a rule that they will see a patient a three times. If they are comfortable with the condition they will continue treatment, if they are unsure about the diagnosis, treatment, etc. they will refer them on. Don't let a patient's true diagnosis go undiscovered.
Be Wary of any Drug Treatment. If you are not familiar or proficient with a medication that a patient needs, don't prescribe it until you are comfortable with treating the patient with that medication.
Be Present. If you are distracted, tired, or mentally in Hawaii, don't treat a patient or do a procedure that can turn out bad. The best way to prevent injury or problems is to be physically, mentally, and emotionally prepared.
Obtain Informed Consent. If you ever do a procedure that could have a negative outcome, obtain consent from the patient and explain completely the procedure, expected outcome, potential risks, and alternatives to the proposed care.
Chart Well. If you are nervous when an insurance company asks to review a chart, you probably could do better. Take a couple extra minutes after each patient to quickly prepare the chart. Don't wait until the end of the day when you have forgotten to add in essential information. Chart what you do when you do it and you should be fine.

These are eight of the steps I take to reduce my own liability. Will they prevent a suit against me or my clinic? NO, but they will help me sleep well tonight and even in the advent that I ever get sued.

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.

Preparing for Emergency Absence

Gretchen Moen — Thu, 19 Feb 2009 14:58:00 GMT

The past few weeks have been quite busy and somewhat chaotic for Eagan Child and Family. Following my absence to care for my father, we suffered another unexpected blow: my partner's mother passed away. Shortly thereafter, our administrator took ill and it seemed like there was no one around to "mind the store." I thought it might be timely to discuss what to do when you "suddenly" cannot run the business.

Do you have a contingency plan outlining how your patients will be handled if you are unable to care for them temporarily? Is there adequate internal staff to help, or do you need to find some to step in? What about administrative tasks?

In the short term, patients are usually able to accommodate your absence by rescheduling preventive care, working with a substitute provider or going to urgent care. If absences happen too often or for long periods of time, the business will suffer. Those extended times are when you need to be creative and provide some services to your patients in anticipation of your return.

Here are a few of the ways I have managed changes in provider time:

shortened office hours and kept an assistant to staff the telephones
used picture phones for assessment and assistance by other specialists
met patients in locations outside of the office
had students work with certified NPs to manage a clinic day
enlisted "volunteer providers" to cover key shifts
diverted patients to other providers in the area and called ahead to alert the providers
kept in contact as much as possible by calling patients at home to check in or asking the office staff to update key patients during provider absences

Clinical services aside, I was not prepared for the management of administrative activities that occur on a daily, weekly or monthly basis. In the recent case of our family emergencies, there wasn't time to gather all the information, write a list of what is pending, assign responsibilities or come up with any plan for other pre-emptive activities to help those who were running clinic. In the end we missed a few scheduled payments and scrambled to get payroll done. Rent went out late. I spent quite a bit of time on the telephone explaining the situation and asking for considerations. Not a good feeling.

I recommend having an administrative operations manual with information that would be useful if you are unavailable for more than 7 to 10days. Here are a few of the items I would include:

E-mail: someone assigned to check administrative e-mail from patients, vendors, regulatory bodies, etc.
Snail Mail: assign someone to open and distribute bills, payments, notices, medical records, junk mail
Patient flow: patient flow is managed daily to decrease the likelihood of potential blocks, inappropriate scheduling, poor planning, time management
Payroll: timecards, how to run payroll and who will be signing checks
Accounts Payable: payment schedules, checks. paying the "float"
Accounts Receivable: including insurance payments, patient payments, billing questions
Pending: audits, taxes, insurance reviews, contracts, malpractice payments, credentialing processes
Students: who will be mentoring the students, or do you need to contact the schools and work to reassign the student
Physical maintenance: telephone, internet, IT, and building management contacts, plumber, electrician, pest control

I am glad the past few weeks are behind us, but I am still dealing with some of the issues that arose from patients and business relationships during our untimely absences. We have started an administrative manual that we hope to complete soon. I am proud of my staff and partner for "keeping it together" as well as they did, and I have learned a valuable lesson in emergency preparation!

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?

Calling All Pennsylvania NPs!

Joseph Marra — Thu, 20 Nov 2008 14:02:00 GMT

Pennsylvania NP regulations are up for legislative review. Letters are encouraged to be sent to the board of nursing by 12/8/08. I wrote one personally that you can read below, and I got several physicians, dentists, NPs, other colleagues, patients, and even representatives to send letters. Please show your support! If you are an NP from another state that is already independent, please write, showing that NP independence is really safe and affordable, and the quality of care provided is equal to our colleagues.

Send your letters to Ann Steffanic, Board Administrator, Pennsylvania State Board Of Nursing, P.O. Box 2649, Harrisburg, PA 17105-2649.

Here's my letter:

November 16, 2008

Dear Ann,

My name is Joseph Marra Jr. and I am a CRNP that owns and operates the "Urgent Care Center" in central PA. I have been independent now since opening my practice February 14, 2006. I would like to take time to write in my perspective, just a few limitations that are imposed to CRNP's by the current regulations. First, many NP's have a limitation in prescriptive authority. Second is the limitation with collaboration with physicians. Third is the inability to prescribe home health and hospice due to certain language or interpretation within the regulations. Fourth is the limitation of admitting privileges into hospitals, just to name a few.

The current prescription authority limits us as well as our pt.'s. Many pt.'s must return every month even when they are stable within a disease process and medication regime, due to the inability to write for refills. This is not only an inconvenience for the pt. but increases healthcare dollars as well. Also several of my pt.s that have chronic pain from histories such as MVA, work r/t injuries, vertebral compression fractures etc. require monthly prescriptions for chronic pain medications, and we are limited to only 72 hours of medication administration. Many pt.'s come in as new pt.'s whose physician has retired or moved out of the area and had already been prescribed pain medications for years for chronic pain, and Adderall for ADHD, and I have to send them away due to my limitation. Another issue with prescription authority is the limitation with writing for suboxone. I work for Pyramid Healthcare, in addition to my own practice and have discussed with the DEA the rationale behind why we as CRNP's cannot write for a Schedule III drug? They responded; "The limitation is from the State Board of Nursing not us". I would be glad to go to the classes required for this extra education in prescriptive authority, but cannot with the current regulations. So many individuals would benefit from being on a maintenance dose of suboxone and ad to their community, as well as re-enter into the work force. This is such an under rated program, that it is disheartening to me. As a profession we compete for jobs and since we have limitations, we are often times looked over due to another individual with full prescriptive authority, even though we may be just as qualified and work for less money. Limiting our prescription ability simply limits access to quality care.

The second limitation that I would like to address would be the access to collaborating physicians. First of all I don't personally feel that this should be a requirement any longer. CRNP's have proven themselves time and time again, as safe and effective practitioners, with study after study. It has also worked in many other states, so why not in this state. Also it is difficult to obtain a physicians collaboration. They usually fear litigation on someone that they have never even seen. Also, if you must collaborate with the physician, and they tell you, you must address the situation a certain way that you don't feel safe or necessary, the pt., as well as the CRNP's license are at risk. Then there is the matter of paying the physician for their collaboration. This increases healthcare dollars as well. In my own family practice I have been not only trusted to make independent decisions but have been consulted by my physician peers for certain things. We as a profession know our strengths as well as our limitations. If the pt. needs something above what we were trained to do, we simply refer to the ER or a specialist, depending on the severity of the condition.

Third, I have had several pt.s that see me for family medicine due to the inability to get in with a PCP, from living in an underserved area. I offer the lowest prices in town, with a basic visit at only $40 per visit, and I use the $4 prescription plan at the local pharmacies as well as giving out free samples. But when NP's are limited to such things as home health, especially when pt.'s really require debilitating in home care, there is no where else to send them. I find it almost inhumane the way medicine is right now. I can provide the service to the pt., however am unable due to a regulation, and therefore a reimbursement issue. I of course don't turn these pt.'s away, but they get to a point where they can no longer make it to the office, and left with lack of proper care in the homes. Family members are left taking care of these pt.s that have a very high acuity. I implore you to take a serious look at our current regulations for our citizen's sake.

The fourth and last point that I will address in this letter, is that of the inability to admit to hospitals. When you think of total access to care, you must also think of continuity of care. When you have seen a pt. for years and know what meds. they have been taking for certain ailments and aware of the illnesses that have developed, but they have to be admitted under another practitioner, the quality of care is less in my opinion. Although hospitalists are worth their weight in gold, some family medicine practitioners continue to see their own pt.'s. My pt.'s continually express a dislike in this matter. I of course have no option but to reply; "My hands are tied". I understand that some hospitals allow for admitting privileges under other physicians. However, the pt. must be seen by that physician within a certain time frame. The decision made by the physician, may not be considered wrong, but not always the exact choice that HCP or pt. would choose.

In Summary, with limited access to primary care well documented, and less and less physicians going into this specialty, it stands to reason that someone must take over this responsibility. NP's are quite capable of taking care of this population. We are well trained, and several studies have shown that at the end of the study, NP's provide equal care to that of physicians and sometimes even better. I can forward you these studies if you would like. NP's make solid decisions and know their limitations as well. After practicing for over five years and being independent for almost three, I can tell you that this office functions quite efficiently with little to no complaints. In fact I will have some of my pt.'s send you their interpretation of the care that I, and my colleagues provide. I will offer my Urgent Care Center as a model if you would like. Take a day and actually come to my office, see how it runs, and ask the pt.'s what there perception of the quality of care is that they receive. I commend Governor Rendell, for his part in making changes that benefit this profession and ultimately our communities.

Thank you for your consideration in this matter, and should you have any questions, please don't hesitate to contact me at the above number. I would be honored to answer any questions you or the board would have, in the possible revisions to our regulations.

Sincerely,

Joseph F. Marra CRNP

Internal Customer Service: The Little Things Really Count!

Gretchen Moen — Tue, 21 Oct 2008 16:37:00 GMT

Internal customer service is often overlooked when you are planning and developing a business. Architects and planners consider the physical aspects of the work place: counter heights, work stations, break rooms, lavatories. Developing a work environment that is pleasant, calm and (dare I say) fun while maintaining professionalism is a bit more challenging.

Typical business models address employee relations through wages, compensation and benefits. Obviously those elements are extremely important, but what else can be done to attract and keep employees?

The last 6 years I have tried to make ECFC a place where patient and staff can feel comfortable and relaxed. I cannot pay my staff a lot, and we are unable to provide insurance or other monetary benefits so we find other ways to make them feel appreciated. I try to say thank you to the staff when I leave at night. I thank them for their help during the day. If I am finished and one of the staff appears to have a lot of work left to do, I help them prioritize the tasks and chip in if I am able. My partner says we treat our employees with respect not because we are not able to compensate our employees the way we would like, but we act this way because it is the right thing to do - and it makes for an efficient and effective work environment.

Never ask your staff to do something you would not do yourself. I have worked in environments where cleaning up patient rooms, finding equipment for a procedure or taking specimens to the lab were deemed to be beneath a provider or manager and would be left for the MA who has six shots to do, three patients to room and phone calls to make.

Respect your staff and their opinions. I am sure we have all been exposed to environments where we felt our thoughts and opinions counted for very little. The feeling is not pleasant. Disregarding an opinion is showing disrespect for the person who voiced the opinion.

Flexibility in scheduling and self-scheduling are working well with our staff. We have staff with a variety of activities and projects outside of work as well as a few with physical limitations. Allowing the staff to talk together and set the schedule puts ownership in their hands as well as accountability for their decisions squarely on their shoulders. As a team we set the schedule based on our needs (one provider, etc.), and they take it from there. We have far fewer short-staff days and we have happier staff, willing to help each other out when unexpected things happen. Our staff has told us they very much appreciate our passing this task on to them.

We are a pediatric and family clinic. I cannot justify criticizing the staff for having to keep a sick child home, scheduling doctor or dentist appointments during work hours or helping an ailing parent. It seems hypocritical. Our staff knows that we insist that family is most important and job is much further down the list. Causing undo stress to an employee because they had a sick child or went home ill when we felt "we would have been able to stay" creates a very negative almost hostile environment.

Letting or encouraging a sick employee to go home actually improves productivity over all. When you are sick your productive work is less than optimal. Our patient care has not suffered because we allowed a sick employee to go home or stay home. If we need an employee who has a child who is home because of a minor illness (24-hour wait for strep, pinkeye and the like) we allow them to bring their child to the office, and we set up an area for play, etc.

We also encourage random acts of appreciation. Periodically we buy "fancy" coffee drinks for the staff or buy lunch for no reason. On particularly busy days when it appears there will not be much time for lunch or breaks, we order in pizza or something that can be eaten on the fly. There is at least one "Dairy Queen" or Culvers run every month. When an employee's washer went out she brought her laundry to clinic until it was fixed. Never once did we feel our employees were taking advantage of us or abusing their position.

Internal customer service begins with you. Your example and your direction can influence the rest of your team. Like the old saying goes, "Treat others as you would have them treat you."