PMHNP: Typical Practice Day for Outpatient Primary Care

00:01 Hi, I'm Jack. I'm a psychiatric mental health nurse practitioner, and I'm going to talk to you today about a typical practice day as an outpatient primary care provider of mental health care services.

00:15 I thought we'd first talk about how patients come to see me as a provider.

00:20 My appointments for new patients are made by my front office staff.

00:23 Patients first fill out general information online, including insurance information and reason for their visit.

00:30 Once their insurance is verified, we will then schedule an in-person appointment. For follow up appointments, we schedule these immediately after a visit, whether it's telehealth or in person.

00:42 All new patients must be seen in person for their initial first visit and at least once every six months. This is good practice to be able to conduct a thorough diagnostic assessment.

00:55 Patient with urgent needs or those in crisis must be seen in person as well.

01:01 If we need to intervene, I need to be able to keep them safe until a plan is formulated. Stable patients have the option to choose telehealth or an in-person visit when both provider and patients are fresh.

01:15 More complex follow-ups are often scheduled in the morning.

01:19 Medication management follow-ups can be scheduled throughout the day.

01:24 15-minute gaps are built in strategically for those unexpected issues or lengthy documentation.

01:32 Most practices allow same day scheduling for urgent mental health needs.

01:36 Telehealth visits might be clustered together for more efficiency.

01:42 The structure of these patient encounters looks something like 10 to 14 patients per day, and that's usually broken down into 1 or 2 new patient evaluations, 8 to 12 follow-up visits, 1 or 2 urgent care slots.

02:00 Patient with those more urgent needs are scheduled earlier in the week.

02:05 Now, let's take some time to talk about how I document everything.

02:10 I personally typically take written notes during the visit, and I only chart on the computer once the patient leaves.

02:17 Some providers like to chart on the computer during the visit, but I prefer to give my patient the full attention during that visit.

02:26 I do use a standardized electronic health record, and that allows me to include a treatment plan presenting problems, treatment frequency, duration, and goals with objectives according to the psych DSM-5 TR standards of documentation. Some of the biggest psych DSM-5 TR standards of documentation include the diagnosis.

02:53 Now, this diagnosis must be the criteria that's outlined in the DSM -5 TR. I must include the presenting symptoms, their severity, and how they impact the patient's functioning.

03:07 And then last, the diagnostic code.

03:10 That's very important.

03:11 It's specific to each diagnosis you sign.

03:14 And you'll need that for insurance purposes.

03:17 A big aspect of documentation is coding for billing purposes.

03:22 The coding process can be completed by time or complexity.

03:27 I personally choose to code by complexity, primarily because this allows me to include a brief psychotherapy session if needed.

03:36 The codes I primarily use and my practice is the 99204, which is for a new patient evaluation.

03:46 99214, which is a routine follow-up .

03:50 It's a mid-level code that is used if the patient has two or more diagnoses, a med refill, or if they have one unresolved diagnosis that I'm working on.

04:03 The lower level code is 99213.

04:06 This is more of a routine for one simple diagnosis or just a simple med refill. The brief psychotherapy code that I use is 90833 . This code is for 16 to 30 minutes for add-on for psychotherapy if needed for the patient.

04:27 And remember these codes are regularly updated, so make sure you check on the current versions to stay up to date.

04:33 A typical primary care day involves coordinating with other providers.

04:38 This is super important.

04:40 Referrals from other providers are usually local primary care providers who we have built a relationship with through in-person visits, business cards, or fliers.

04:51 Referrals to other providers are usually made over the phone.

04:55 Patient records are exchanged via HIPAA-secure fax or email.

05:00 If you're lucky, you have a front office staff to manage this process.

05:06 Another aspect of my practice day that I would be sure to cover is how often I use screening tools and assessment protocols.

05:14 You learn about these in your training, but you need to remain current.

05:18 If these get updated or changed, you want to use the most current ones.

05:23 Use of the best tools gives you good data and can affect not only your billing, but your credibility as a quality provider.

05:31 For example, current practice includes screening every new adult patient for depression with the PHQ-9 or the Patient Health Questionnaire, which has nine specific questions designed to assess levels of depression in adult patients.

05:49 Full medication lists are important with past and present medications, and these should be collected on every new patient.

05:58 We also run a report from the Prescription Monitoring Program or the PMP. This PMP-aware database is a state-run electronic database that collects, monitors, and analyzes information on prescribing and dispensing of controlled substances.

06:19 This kind of gives us a snapshot of what patients are being prescribed, who's prescribing them, and the last time they picked those medications up. Another routine screen is for anxiety, suicide risk. And of course ADHD are common for new patients.

06:37 Another aspect of a typical day is thinking about having an integrated treatment plan.

06:42 I try not to get stuck just thinking about the mental health aspect of my patients.

06:48 Most of your patients will have multiple issues.

06:52 This is pretty common.

06:55 U sually patients will always have more than one diagnosis.

06:59 Patients with medical and mental issues together, we have to stay aware of their current medical treatments due to medical interactions and med induced exacerbations of some of their medical conditions.

07:12 To integrate the treatment, we carefully look for med interactions.

07:16 Some meds can affect sodium, cardiac, QT levels, blood sugar, and etc..

07:22 Reviewing these labs with a bigger perspective is always a good practice.

07:27 Time management and balancing the schedule is a big topic for a primary care schedule. I learned early on as a new practitioner that time management was super important.

07:40 If you don't manage your time wisely, you'll be running over on your other appointments very quickly.

07:47 So to help me stay organized, what I started doing and I continue to do to this day is I come in 30 minutes to an hour before my first patient.

07:55 I review their intake forms, the previous notes, such as they may mention that they had an MRI on a shoulder scheduled. They may mention that they haven't been sleeping well.

08:10 They started a new job and that's causing more anxiety.

08:13 So I'll follow up with those questions and it makes the patient feel more valuable and that I'm more engaged as a provider.

08:22 Some of the other things that I look at is I'll look, if they need a refill for the med, so I'll know before the appointment that they need refills and they don't have to ask me.

08:31 I'll get those done for them.

08:33 And a lot of patients appreciate that staying on top of those meds.

08:39 Lessons I learned from mentors about scheduling is you also have to be balanced about doing small talk with the patient.

08:48 You have to kind of take the time.

08:49 The patient doesn't want to feel rushed.

08:52 So you want to start the assessment out with how's their job doing? How's the family? How's the kids? But in the same sense, you also have to control the assessment at all times.

09:06 That's just super important.

09:08 And I think you can do a balance of the two between small talk and staying on time, if you're careful.

09:15 Interdisciplinary collaboration is when you need another discipline involved, such as therapists, psychologists, primary care, or even OBGYN. You really need to network with these specialties in your area. Sometimes, all that is needed is a simple phone call to pass any patient information or to ask for assistance.

09:37 Handling urgent care needs, I can always squeeze a patient in if needed that has urgent needs, especially at the end of the day.

09:47 Usually, my last patient is scheduled for four.

09:51 Usually, I plan on staying till five doing documentation, so that gives me 30 minutes that I can usually squeeze a new patient in if needed.

10:01 It usually only happens about once a month, but when it does, it's nice to have that spot open for the patients.

10:08 A lot of primary care providers will double-book their appointments, like they'll book two patients for nine, two for 9:15.

10:17 And what they're trying to avoid is no-show patients.

10:20 This is usually a big problem even with me.

10:24 I usually have 1 or 2 no shows a day that didn't give us any notification that they weren't coming.

10:31 So primary care providers will double book to kind of avoid that.

10:36 A last-minute add-on will affect the schedule somewhat, but it's usually not that big of a deal for me.

10:43 Now when we talk about suicide concerns, this is something that's going to happen guaranteed in all practices for psych.

10:51 And when that patient comes in and is identified with a suicide concern, what we need to do is immediately room them, get them out of the lobby.

11:01 The provider will come in and assess them and determine if an intervention is necessary.

11:06 If intervention is necessary, what we'll do is remove any objects that could cause any harm from the patient and the room.

11:14 If they are alone and don't have any family or friends with them, and they do need an emergency intervention, we'll call the ambulance and transfer them to the nearest ER. If the patient is uncontrollable though, or in danger to others, we will call 911 for police intervention.

11:34 Now, when we talk about private practice and psych, there are some pros, there are some cons.

11:41 A couple of the big ones for me, a pro is I don't have a typical 8 to 5, Monday through Friday schedule.

11:49 I'm able to flex that schedule, change some patients around if I need to, if I'm if I want to have a longer lunch or if I don't want to take a lunch, I can change that. It's a very flexible schedule, but on the same sense a con is what do you do if you're the only provider to practice and you're sick or what if you want to take a vacation? You need to have a plan in place for that.

12:14 What a lot of providers do is you'll never work with another psych nurse practitioner area, and you guys will cover for each other if sick or vacation if needed.

12:27 A big thing about being a provider is how to manage professional boundaries. It's super important topic to think about working as an advanced provider in primary care.

12:39 You're going to become very close with some of these patients.

12:42 They're going to share some of their deepest, darkest concerns.

12:46 And sometimes the patient likes to take liberties with that. Like sometimes patients will send me friend requests on social media or ask for my personal phone number to get in touch with me.

13:00 Resist doing this. Don't do it.

13:04 And another thing you might consider is something I did when I first became a nurse practitioner is I found a privacy service that wipes all your personal data for you on the internet.

13:17 It'll leave your professional information, but takes away all the stuff that usually pops up on the internet about, such as your home address, phone numbers, etc.. My final thoughts are that outpatient private practices can be very rewarding and fulfilling choice for psychiatric mental health nurse practitioners, and I hope these insights have been helpful to you.

13:43 If developing longer-term relationships and being able to follow your patient's progress is appealing to you, consider looking into becoming an outpatient primary care provider.