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How I Plan to Get Out of a Rut in 2020

2019 has been a bit of a rut for me. Here’s what I plan to do to shake things up in 2020!

My accomplishments through the 2010’s:

December 2012 Completed BSN

February 2013 Passed NCLEX

March 2013 Started 1st nursing job

August 2014 Started BSN-DNP

December 2016 Completed MSN & Passed ANCC Boards

January 2017 Started 1st NP Job

July 2017 Completed DNP

March 2018 Opened Telepsychiatry Business

2019 *Crickets*

It’s a strange feeling. My entire life I focused on achieving the next academic success or the next best career move. Now my academic career is complete, my practice is as big as I want it… and what now? How do you mentally shift from measuring your success through academics and career achievements when that has been your measure of success for so long? In 2019 I have struggled to find my next move. Earlier this year I thought I would try medical writing and quickly realized I don’t have the knowledge or experience I would need for that. Then I thought I would try to break into the field of research. Again I realized that I don’t really have the knowledge or experience. What I am trained to do and what I do best is take care of patients. So, how do I grow from here? As I watch everyone else discuss their accomplishments from 2019 I realize that I have had no major accomplishments this year *Yikes*. I think 2019 has been a bit of a rut for me professionally. And being in that rut leaves me feeling burnt out. So, today, on this very last day of the decade I am going to make an action plan to get out of a rut in 2020.

My professional goals for 2020

Educate others and share my experiences. As I started blogging over the last week I began to feel a passion and excitement professionally that I haven’t felt in a long time. I realized I love teaching. I love sharing my experiences. I’m excited to carry this excitement into 2020.

Reevaluate my patient encounters. I currently do 15 minute medication checks. I’m going to research how to make these encounters more meaningful. On the practical side of that, I will see if I could maintain my current compensation by billing for longer appointments. I’m going to see how I can strike a balance between quality and quantity.

Study a new subspecialty. I am very interested in adding another subspecialty. There is a huge gap in the healthcare system between women’s health and mental health. I’m very curious to investigate and find new ways to help and educate my female patients. I’m also interested in weight loss within the mental health community. I don’t know if I can commit to becoming certified, but at the very least I would like to increase my knowledge about how to help my patients live healthier lifestyles.

My Personal Goals 2020

I have to say exercise, right? Isn’t that mandatory on this list? Seriously though, I attempted a good exercise routine multiple times in 2019 and it would stick for a few weeks and then fade away. I tried Orange Theory (which I absolutely loved by the way), but then I got tired of waking up at 5am (I am NOT a morning person at all). I got into a cycling routine for a bit and thoroughly enjoyed that, but it just kind of faded away too. So 2020 is the year to establish a routine. I don’t need it to be insane. I will take any routine I can get… more to come another time on what that routine will look like.

I will start a hobby. I have never had a hobby. EVER. I have been invested in academics for so long that all my mental energy went to writing papers, studying… all the school things. Now I am so used to spending all my time doing something I had to do, that I don’t know how to enjoy doing something just for the sake of doing it. I don’t know the hobby yet, but 2020 will be the year of hobby!

I have never put my goals in writing. So, here it is, published on the internet for everyone to see. At the end of 2020 I will come back and evaluate how I did! 2020 won’t be another rut year and I don’t need academic structure or a new career to make that happen! This is going to be a totally new experience for me and I will provide updates periodically on how it’s going.

Have you been in a rut recently? What are you going to do to make 2020 a better year? I’m open to any suggestions you might have to add to my list! I can’t wait to hear from you! Please leave your thoughts in the comments below and go to the home page to subscribe and get the latest content!

5 Steps to Help Patients Achieve Sobriety

I have 5 steps I follow every time to help my patients struggling with substance abuse. Find out what they are!

Welcome back everyone and thanks for joining! I’m so excited to see so many new subscribers! Thank you so much for the support and I hope you enjoy the content!

Today let’s talk about how to treat substance abuse! I’m calling it “The Pathway to Recovery.” I find many psychiatric nurse practitioners shy away from treating addiction. I was weary of it in the beginning as well, but you know what? It’s a niche I just kind of fell into and I really enjoy it. It’s a wonderful subspecialty in psychiatry and understanding how to treat addiction can open up a whole new patient population to you! I’m going to give you 5 steps to treat substance abuse patients! If you follow these 5 steps you can’t go wrong! I use this approach with my patients and, guess what? It works! I’m attaching the patient handout portion and an explanation of how to use the handout. Below I will explain my methods in more detail!

Step 1: Assess Motivation

Assess whether the patient is motivated to get sober. Yes, patients will walk into your office and NOT be ready to commit to treatment! Their partner, friend, or relative convinced them to come and they are trying to appease them. When working with the unmotivated patient, you will feel their resistance throughout the assessment. They will often deny that their substance use is really a problem. They will also REALLLLLLY resist medication. When this starts to happen LISTEN TO YOUR GUT! Ask the patient right away, “Do you want to get sober?” Because this process is going to be hard. It’s going to take commitment. They must be ready and motivated! Some of your patients will be ambivalent (remember the Transtheoretical or Stages of Change model in nursing school… yup, here it is!). These patients may partially engage and be willing to do some of the treatment plan, but not all. Maybe they will take a medication but not go to therapy. Meet the patient where they are. When I have an ambivalent patient who is only partially engaged I like to say, “Okay, let’s try it your way first for a month. When you come back next month if you aren’t sober we will try it my way.” They usually agree! You must get the patient to buy in and build rapport and this is part of that. If your patient is ready and committed, you are ready to jump onto the pathway to recovery!

Step 2: Assess Whether the Patient Needs to Detox Inpatient

Always ask yourself, is it safe for this patient to detox and achieve initial sobriety in an outpatient setting? MOST of the time, the answer is yes. In three years, I can only think of a handful of patients I recommended inpatient detox for. What may be an indicator that a patient needs inpatient detox first? Lack of support at home, moderate-severe withdrawal symptoms, medically unstable (particularly if their blood pressure is elevated or they are high risk for seizure), or psychiatric instability (psychosis, mania, suicidal thoughts). All the patients I sent inpatient for detox were medically unstable and/or having moderate-severe withdrawal symptoms. Blood pressures were sky high, they appeared extremely unwell, and had severe tremors. If your patient appears unwell and you are concerned for their physical health DO NOT IGNORE YOUR GUT! Patients detoxing from alcohol or benzodiazepines are your most medically high-risk patients. Opioid detox is uncomfortable, but not deadly. Alcohol and benzodiazepine detox can be deadly. If I am concerned and really feel strongly the patient needs inpatient detox first, I am very straightforward about how serious the detox process is. I say, “Detoxing from alcohol (or benzos) is extremely serious. You can have seizures, hallucinate, and be very ill. If you go inpatient you will be prescribed medications that will make your detox a lot safer and more comfortable.” If your patient is hitting close to 48 hours without alcohol they know what you’re saying is true and often they will take your advice. Once they detox, they can return to you and resume outpatient care.

I have found inpatient detox to be the fastest, safest, most reliable way to get patients to detox. They have no access to alcohol or other substances, they are medically monitored, and they are getting introduced to group therapy and support groups. Going inpatient is a significant event for most patients and leaves a major impact on them which also provides good motivation not to relapse in the future.

Step 3: Prescribe Relapse Prevention Medication

Your primary role in this treatment plan is 1) Get your patient to the right treatment setting and 2) Make sure your patient is on the right medication. If they go inpatient to detox they may come back to your office on the right medications, but you need to be sure! Substance abuse patients are more likely to stay sober with medication to prevent relapse. I like to explain to my patients “Medication is a very small, but important part of the treatment plan. The right medication can give you the foundation to move forward.” Take a look at the corresponding handout to see more about when to use each medication. In the handout I don’t go in depth on how to treat benzodiazepine abuse. That is a whole other topic that I have a really great handout for. You will most commonly treat alcohol, opioid, and cocaine dependence. Marijuana dependence is extremely common, but there are no medications studied or approved for marijuana dependence at this time. Some BIG KEY POINTS to keep in mind are DO NOT START NALTREXONE UNLESS THE PATIENT HAS BEEN OFF OPIATES FOR 7-10 DAYS and DO NOT START ANTABUSE UNTIL 24 HOURS AFTER THEIR LAST DRINK. Be sure to give your patient a list of products and foods to avoid while taking Antabuse. On that note, though, let me add that I have NEVER had a patient say, “Oh man I accidentally used too much aftershave and had the worst reaction” or “I ate chicken marsala and got so sick.” It doesn’t usually go that way. So, reassure your patients that as long as they avoid alcohol and do their best to avoid the things on the list they will be just fine. Antabuse takes 1-2 weeks to completely leave the body. So, having your patient on Antabuse provides an excellent long-lasting safety net.

Be sure to assess for comorbid psychiatric conditions. In my experience, 20% or less of patients presenting with a substance abuse disorder ONLY have a substance abuse disorder. The other 80% of patients have a comorbid psychiatric disorder. Make sure you prescribe the appropriate medications for these co occurring psychiatric disorders as well.

Step 4: Refer the Patient to a Substance Abuse Counselor

This part is so important. First, this adds an additional layer of accountability. Your patients need as many points of accountability as possible. Second, your patient doesn’t know it yet, but they are going to experience multiple phases during their recovery. The first phase (we call it the “pink cloud phase”) everything feels so wonderful and the patient is over the moon they are sober. That phase eventually evolves into a more ordinary phase where reality settles in and the excitement of sobriety has worn off. Patients need a lot of help working through this phase and onto the next ones. Patients who don’t have a therapist and aren’t anticipating this get caught off guard and are very high risk for relapse during this time. A good therapist will help the patient anticipate this new phase and can give your patient the tools to navigate through it.

Step 5: Pick a Support Group and Start Attending ASAP

Here is another layer of accountability. I am a big advocate of “90 in 90” which means a patient will attend 90 meetings in 90 days. These meetings keep their sobriety at the forefront. There are different types of meetings for everyone. The corresponding handout lists the most common support groups, their websites, and the theoretical basis for each group. If your patient attends meetings they are significantly more likely to stay sober. Also encourage your patient to get a sponsor! If your patient can only see a therapist OR go to meetings, I would encourage them to go a support group every time! This part of the puzzle is absolutely critical. Best of all, the meetings are free.

Now you are ready to treat substance abuse patients like a pro! Don’t shy away from it! Follow these steps and you will be able to have the joy of helping so many people achieve sobriety and change their lives! Now I need your feedback. The attached handout is a sampling of the type of handouts I plan to make in the future. My goal is to make a blog post that explains a concept in detail and make a handout you can use in an appointment with the patient (that will hopefully save you time explaining things) and a quick reference sheet you can put in a binder. Does this handout have too much information? Too little? Is this post too in depth? I want to provide you with the most practical information and tips to give you confidence in your practice. Let me know how I could make this information better for you! I’m looking forward to your feedback! I probably won’t leave this handout up permanently if I decide to include it as part of the Psych NP Resource File. So download it now!!

8 Steps to Set Up Your Business as a Contracted Healthcare Provider

Here are the steps I took to set up my business as a contracted psychiatric mental health nurse practitioner

Today’s post is dull, but necessary. It’s not going to be a pleasure to read, but it’s information I want you to have. Today we are going to discuss how I set up my business as a contracted nurse practitioner in Georgia. It took me a lot of digging and research to figure this out. So, I hope laying out these steps will save you a significant amount of time and stress! Please keep in mind I am not a professional in legal or tax matters. These were the steps I took and it has worked for me!

If you are trying to make the decision to be a contracted or salaried employee check out this post: https://nursekierston.com/2019/12/24/my-first-blog-post-contracted-or-salaried/

Why do you need a business as a contracted healthcare provider?

Let’s start by talking about why you need this information. If you are a contracted employee, it’s a great idea to set up a business to employ yourself for two main reasons. First, it can help you save money in taxes (and we all love saving money). Second, it can provide you a legal layer of protection. Now let’s jump into how to do this. It’s grueling, but I promise to make it as concise and easy as possible!

Step 1: Choose a business name

This is fun, but don’t overthink it! It can be your name or a name you come up with. Think about what you plan to do with your business in the future. Will you use this name to start your own practice? Do you just need this name for contracted employment agreements?

Here’s the link you would use to see if your business name is available in Georgia:

https://ecorp.sos.ga.gov/BusinessSearch

Step 2: Register Your Business

Go to this link https://ecorp.sos.ga.gov/Account to create an account with the Georgia Corporations Division. Once logged in go to “Create or Register a Business.” From here just follow the prompts. I created a “domestic limited liability company.” I selected NAICS code “Healthcare and social assistants (62) and NAICS subcode “Office of mental health practitioners (except physicians) (621330).” When entering an address for the business recognize that this address is going to be public record. So, you may want to choose a PO box if possible. Complete the rest of the information, pay $100, and voila! You are now a proud owner of an LLC! Be sure you keep receipts and any emails you receive confirming your registration to provide your CPA during tax season. You can also deduct (or expense??) your start up fees!

Step 3: Apply for an EIN

An EIN is like a social security number for your business. This number is how the IRS will be able to identify your business. You will receive your EIN to write down once you complete your application and you will receive it in the mail a few days later.

Here’s the link to apply for an EIN:

https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online

Step 4: Apply for a state tax ID and withholding number

This is not required in all states. In Georgia this is required. You will be making tax payments to your state and to the IRS. Your state tax ID allows you to make your state tax payments. Here is the link for the starting point to get a state tax ID and withholding number:

https://georgia.gov/popular-topic/state-taxpayer-identification-number

Step 5: File form 2553 with the IRS to be taxed as an S Corp (optional)

This step is completely optional. Completing this step allows you to file your taxes as an S Corp instead of a sole proprietorship. I am not a tax professional. If you have read my other posts you know how much I hate taxes. So, in simplest terms, if your business is taxed as sole proprietorship (which is what your LLC will automatically be taxed as if you do not file to be taxed as an S Corp) all your income is subject to all the taxes you pay. If you are taxed as an S Corp, you will pay yourself a reasonable salary which will be fully taxed. All your other income is taxed at a lower rate. Once the IRS has received and approved form 2553, you will receive a letter in the mail stating you will be taxed as an S Corp. This can take several weeks.

Here’s a link to IRS form 2553 and the instructions for the form:

https://www.irs.gov/forms-pubs/about-form-2553

Step 6: Sign up with a payroll service (if you are going to be taxed as an S Corp)

If you are going to be taxed as an S Corp and need to pay yourself a salary, you will need a payroll service to manage your salary and payroll taxes. I use OnPay. They have been super simple to use, very reliable, and have been very responsive when I needed help (and I needed A LOT of help).

Step 7: Sign up with an accounting software

Register with some type of accounting software. I use Quickbooks online. I don’t find it to be the most user friendly and my CPA usually has to fix some things at the end of the year, but it’s cheap and it gets the job done. I just connected my bank and credit card accounts and each month I go in and make sure all income and spending has been categorized. To be totally honest, I really only do this quarterly and sometimes less, but even when I put it off it only takes me about an hour to get all caught up. Quickbooks also allows you to generate all the reports your CPA will need to plan and complete your taxes which has definitely made tax season much easier for me.

Step 8: Get a fantastic CPA

I am a big believer in having people around who are experts at what they do so I can focus on being an expert at what I do. So, find a fantastic CPA so you can just give them the documents they ask for and you can be on your merry way. Filing my taxes as an S Corp typically costs about $800-$1000 per year.

You are all set! Hopefully I made this process easy-ish for you! If you have questions or thoughts, please comment below. Do you hate taxes as much as I do? Let me know in the comments! Also, go to the home page and subscribe to be notified each time I make a new post.

“Do I need a Doctor of Nursing Practice degree?”

I completed my DNP. Here’s what I think about it.

Welcome back! We are doing a bonus blog today! Stay tuned for more bonus blogs during our first week! Today’s topic is a bit controversial. “Do I need a Doctor of Nursing Practice degree?” I completed the DNP program and I’m going to tell you all my thoughts. Did it make me a better healthcare provider? Do I have a leg up when applying for jobs? Do I make more money? What did I learn in the DNP program that I didn’t learn in the Master of Science in Nursing (MSN) part? Do you need a DNP degree to start practicing? Let’s talk about it!

Does a DNP make you a better healthcare provider?

In my humble opinion, NO. Again, NO. I do not think my MSN prepared colleagues are any less prepared for clinical practice than I was. MSN and DNP students learn the same assessment, diagnostic, and medication management skills. There are no secrets to clinical practice handed out in the DNP program. An MSN prepared NP is just as prepared for practice as the DNP prepared NP. Yes, you do additional clinical hours in the DNP program, BUT while you are still doing clinical, your MSN colleagues are working the same amount or more hours. The DNP portion of the program did give me the opportunity to study a specialty in psychiatry, BUT you could learn a subspecialty by working with a physician who has a subspecialty. So, do I think someone with a DNP is a better healthcare provider? No.

Does having a DNP make a difference when applying for jobs?

It depends. A DNP is required for most advanced practice program teaching positions. A DNP may give you a leg up if you want to work in research. However (get ready for a side tangent), breaking into the field of research is very difficult even with a DNP. Research positions often want to see experience or a degree that taught you what you need to know about being in a lab and the research process. Medical writing positions want to see the same thing. The DNP prepares you to practice (just like the name of the degree implies). Practice is more focused on being a consumer of research. Whether you have a DNP or MSN you are being prepared to provide patient care. In the end, that is what your degree qualifies you most to do. If you want to get into research or medical writing you will probably need more training than you got in the DNP program (okay, side tangent over). If you are applying for a nurse practitioner position in an office, hospital, or any other patient care setting, the employer likely does not care if you have an MSN or DNP. In my office, all the other NPs are MSN prepared and we all do the exact same job and there is no difference between us other than the letters after our names.

Do you get paid more for having a DNP?

Well, it would be nice to see a return on the extra time and money you spent on school to get your DNP. However, I personally have not received any additional earnings because of my DNP and I have never seen a job posting that says they will pay more for a DNP. I have never heard of anyone with a DNP making more money. So, from my personal experience, no, a DNP degree does not increase your salary.

I’m having this debate in my head right now… part of me wants to argue that more education should be equivalent to higher compensation. On the other hand, an MSN and DNP are licensed and certified to do the exact same job and are equally capable. So, why would a DNP make more? Feel free to argue with me on this point because obviously I’m arguing with myself about it.

What did I learn in my DNP program that was not in the MSN program?

The core knowledge and skills you learn to be an NP are the exact same between the DNP and MSN program. There are no extra assessment, pharmacology, or core skill courses in the DNP program. As a very general statement, I would say I learned more about healthcare systems, leadership, and research in the DNP courses. Does this knowledge matter? Maybe. It depends on your role and what you hope to do in healthcare. The largest part of the DNP program was creating, implementing, and evaluating an evidence-based practice project within your clinical site. This experience taught me how to identify quality research, identify opportunities for performance improvement, how to create and implement an evidence-based solution, and how to evaluate the effectiveness of the solution. Does this knowledge matter? Again, maybe. It really depends on your role and what you hope to do in healthcare. I use this knowledge when I come across problems where I work and I felt more equipped to start my own telepsychiatry business (more on that another time). It also gave me a deeper appreciation for the nursing profession and made me feel more empowered to be an agent for change within the healthcare system. Since the DNP program trained me to think about issues on a system level I consider how a suggested change will impact every part of the system. What will it cost? What will be required of each person involved? How will affect the practice as a whole? I’m not saying that an MSN prepared NP couldn’t do this same process. However, this was not knowledge I had prior to completing my DNP project.

Will a DNP ever be required for entry to practice?

Probably not. Rumors that the DNP will be required for entry to practice have been floating around for years. It’s important to recognize that what nursing organizations “recommend” and what is actually “the law” are two different things. So, even if nursing organizations make the statement that they recommend a DNP for entry level to practice, the laws have to change for it to become a requirement. You could compare this to the field of nursing’s recommendation for a BSN for an entry level RN, but since legislation never changed the ADN is still available. The ADN v. BSN debate has been around for much longer than the MSN v. DNP debate so in my opinion the MSN is not going anywhere. That is just my opinion. I could be wrong, but it seems unlikely that the DNP will become more than a “recommendation.”

Should I get my DNP?

So, I don’t make more money and I don’t qualify for more jobs. Why in the world did I get my DNP? Well, I had the option to do a BSN-DNP program which shortened the time it would take me to get a DNP. I had my DNP only seven months (two semesters) after I had my MSN. It was a good time in my life to do it. What are some things you could consider when making the decision? Would you benefit from a better understanding of the healthcare system as a whole, performance improvement processes, and learning how to consume and use research? Do you want to teach? Do you want to pursue a career in research (even though you will probably need additional training outside the DNP to do so)? Does it make you feel better to know you have a “terminal degree?” How long do you have to commit to school? Do you know you want to spend your career in patient care? Instead of the DNP, would it benefit you more to get a postgraduate certificate or become certified in a second specialty (like psychiatry and family practice or psychiatry and women’s health)? Do you plan on pursuing a role in nursing leadership and management (DNP training would really shine in this role)?

No matter whether you choose to get an MSN or DNP, I am thrilled you have decided to become a nurse practitioner. You are needed! You are going to love your career as a nurse practitioner. The relationships you develop with patients when you are responsible for their care is so rewarding.

My final thoughts… if you have the option to get a DNP, sure. Why not? Obviously, I’m not a huge advocate for the DNP. I think I learned some really great skills in leadership, research, and performance improvement, but it does not make much of a difference in my current position as a psychiatric nurse practitioner. If I could go back I would probably pursue a postgraduate certificate in a different specialty that would complement psychiatry. However, I have no plans to enter the field of research or academics and I do not plan to pursue a role in nursing leadership. The DNP would be fantastic for those career paths.

What are your thoughts on this? If you have a DNP, have you found it useful to your practice? If you are a student, do you plan to get an MSN or DNP? Please comment below and subscribe to get notified when I post new content!

"Can I have time off work?" How I handle requests for extended leave of absence

Today we will discuss how I handle requests for an extended leave of absence as a psychiatric NP.

Welcome to post two! I’m so excited to see more people joining today! This one is going to be a doozy! But here we go… If you have been practicing as an NP (or PA – let’s include PAs here!) for any length of time, you have encountered it. A patient comes in for a first time appointment and as you go through the evaluation every question comes back to work.

“How have you been sleeping?” “Oh horrible, I’m so exhausted at work.”

“How is your concentration?” “Terrible, I can’t get anything done at work?”

“How’s your mood?” “Terrible, I can’t stand to be around my co-workers.”

You know what’s coming next. You get a lump in your throat as you attempt to finish the evaluation and the patient says, “Oh one more thing, can you fill out these forms for me? I need time off work.” AHHHHH!! You KNEW it was coming! You KNEW it! Nonetheless, the tension in the room mounts as you try to figure out what to do next…

There’s a couple of different scenarios that led to this moment. By the time the patient makes it to a psychiatric NP, it’s possible someone in primary care already saw them, gave them a few weeks off, and when they were not ready to return to work referred them to psychiatry for more intensive treatment. Or primary care referred them to psychiatry immediately. Or they have missed a lot of time at work for mental health symptoms and now they are seeking treatment for the first time since they have used up all of their sick leave and need to apply for FMLA and/or short term disability. Now the patient fully expects for their leave of absence (whether through FMLA or a short term disability claim) to be extended and for the time between their primary care referral and the time they made it to your office to be covered as well. WHAT?? Where in the world did they get this idea??

At this moment I am thinking SO MANY things. Why would you stop working prior to receiving this recommendation from a medical provider? How in the world would I be able to cover time off you missed before you were even my patient? WHY are we meeting for the first time and things are now so serious that your mental health concern is cause for “disability???”

You can say this sounds heartless. That’s okay. Once you have been faced with this situation 101 times you have to be start being a bit more objective. Don’t get me wrong, if an established patient needs medical leave, like REALLY needs medical leave, I am your number one advocate! If a new patient is truly ill enough to impair their ability to work, I’m here for you. If a patient needs time off work to seek more intensive treatment, I will absolutely go to bat for you. But let’s be honest… 95% or more of our patients seeking medical leave (at least in psychiatry or for psychiatric purposes) are not sick enough to merit taking an extended leave of absence from work.

So, what do I do next? First I have to shut down my personal feelings. My personal feelings are work is good for people. A busy and productive mind is a happy mind. I believe my patients need to be working, volunteering, doing something that gives them the opportunity to contribute to society (if at all possible) which will have a huge positive impact on their mental health. For this interaction I have to place these thoughts in the back of my mind.

Once I can shut down my personal feelings I start to EDUCATE. I have found education to be the savior in MANY difficult situations. I educate the patient on the purpose of FMLA and short term disability. I educate the patient on the process of applying and advise that MOST times the short term disability claims in mental health are denied so they may end up never getting reimbursed for their time off. I say, “Insurance companies approve or disapprove your time off, not your provider. I can make a recommendation, but ultimately it’s in the insurance company’s hands.” Then I dive into discussing the best way to treat their mental health concern (which is the whole reason they are in my office, right?). At this point, the patient believes the best way to treat their mental health concern is to take time off work. This thought has to be reframed and again we EDUCATE about what will REALLY help their mental health. We discuss medication, therapy, and more intensive treatment options. When I need to be VERY direct I say, “If your mental health concerns have become severe enough to merit a disability claim, then we also need to discuss inpatient treatment (or partial hospitalization treatment at the very least).” Treating a patient who is so severely mentally unstable that they cannot perform their job functions and need an extended leave of absence means that they are likely not a good candidate for traditional outpatient psychiatric services at this point in time. Outpatient treatment offers you a 15-20 minute visit with the NP/PA/MD biweekly or monthly and then weekly therapy (if a therapist is available, they can afford it, and/or their insurance will cover it). That is just not enough. If someone is seeking a leave of absence for medical reasons the person is likely having surgery, doing physical therapy, birthing a baby. They are doing something that requires their time and energy be invested in the healing process. Why should psychiatry be any different? Taking a leave of absence and dedicating only one hour a week (or less) to mental health treatment is simply not productive.

What happens next? Once I have given the patient all of this information the end result varies widely. If the patient was only seeking an extended leave of absence, they usually leave upset. If the patient is in need of help and ready to work toward recovery, I provide a list of partial hospitalization programs and my patient starts making calls that same day to start treatment. At the start of my career I had a VERY hard time saying no or delivering news people wouldn’t want to hear. So, on several occasions I gave in to patients who requested an extended leave of absence and let them refuse more intensive treatment. Do you know what happened? The patients met with me once every other week for the length of their time off, reported no change in their symptoms, and at the end of the leave of absence we were in no different shape than at the start. They requested another extension on their leave of absence over and over again. Most of the time these claims were denied and sadly once the leave of absence was over, so was the patients willingness to attend office visits. I quickly realized that telling the patient what they wanted to hear was not helping them at all. So, my methods changed. Once patients started engaging in partial hospitalization programming they raved about how beneficial it was and were more ready to return to work with new coping skills and a much better frame of mind. One patient even told me, “Everyone should have to go through this program when they start mental health treatment. It changed my life.” That’s when I realized that to really help people I might have to ruffle some feathers along the way.

So, now the patient has gone through treatment, they return to work, and they come back to you two weeks later and they are decompensating again? What then? It’s very important to decipher between a patient who has a mental illness that prevents them from working and one that dislikes their job. If a patient dislikes their job or their boss they won’t like the answer… find a new job.

What are your thoughts on handling short term disability claims in psychiatry or other specialties? How often are you faced with this? How do you handle it? Leave a comment below! I can’t wait to hear your thoughts! As always, thanks for joining!

My First Blog Post! Contracted or Salaried????

Welcome! I am so excited to make this very first blog post on my very first blog! Today I want to jump right in. I promised to talk about the things you REALLY want to know and that we will do. Let’s start by talking about one of the very first things you will have to decide when you begin your career as a nurse practitioner (NP)…

Should you work as a salaried or contracted employee? BIG DECISION! And both have pros and cons. I am going to tell you EVERYTHING you need to know to make the best decision for you.

Let’s start with working as a contracted employee. Contracted NPs own their own business and through the business provide a service (patient care) to a facility in return for a certain amount of money. Pros: You are your own boss. You set your hours (to a certain extent), you get paid based off your production, and typically you make more money than a salaried employee. I know what you are thinking… “Freedom? Flexibility? More money? Sign me up! I see no cons!” HOLD ON THERE! Let’s talk cons because there are plenty. Cons: You ONLY get paid based off production. This means your pay may vary greatly month to month. You think often about how much you bill and hope insurance is paying on time. You are concerned with patients paying their bills. Your income will eventually hit a semi-reliable amount if you work at a good office and maintain a steady patient flow, but it will still probably vary a couple thousand month to month. That brings up another con: Concerns over patient flow. What happens when another provider gets hired at your practice or for whatever reason your patient flow slows down? It happens. Just like any other industry you have good months and slow months. Also, you are responsible for building your practice. So, the first several months your pay may be very low until you build up a good patient base (this took me about 6-9 months). Another con: You pay for your own insurance, continuing education, license renewal, malpractice insurance, AND you have to manage your own taxes. TAXES???? Doing my taxes gives me SERIOUS anxiety every year AND it’s expensive to pay someone to do your taxes. So, yes you are free, flexible, and can make more money as a contracted NP BUUUUT you worry about your billing, pay for all your own licensing things, and the worst part… TAXES… *shivers*

Now let’s talk about being salaried. Salaried is like hitting the easy button. Everything is set up in a nice little package and wrapped with a beautiful bow. Pros: You know exactly what you will make, you will be offered insurance, you have paid time off, the facility will likely contribute to the cost of your continuing education, pay for license renewal, credential you with insurance companies, AND BEST OF ALL your taxes will be super easy because you are an employee. You hand a tax guy your W-2 and VOILA – taxes done. Now let’s talk cons… You will likely be a full time employee (Monday through Friday 9-5), you have to request time off and you are only allowed a specific amount, you will likely be offered MUCH LESS per hour (like 50% less… eeeek), and you are not getting paid off production (meaning your employer can ask you to do as much or as little as they want and you see no difference in your pay). So, less freedom, lower pay, less flexibility… BUT SILVER LINING – you don’t have to worry about the business side of the NP world.

Let’s talk about the compensation piece of this in more detail. Contracted employees are usually paid a percentage of what is COLLECTED (not billed, COLLECTED). A typical percentage split in my area is 60/40. 60% of collections go to the NP and 40% goes to the collaborating physician for overhead and supervision fees. I have heard rumors of places offering 70/30 and even 80/20 but I have not met anyone personally who received this offer. Another common arrangement is getting paid a set amount per patient seen. I have never heard an amount offered that was anywhere near fair in this type of arrangement. It is usually an offer of less than 50% of what you would actually collect per patient you see. Commercial insurance companies reimburse $75-$100 for a follow up psychiatry visit roughly. You can calculate what compensation would look like hourly/daily based on how many patients you plan to see ([$ collected per visit x # patients seen per day] – 40% to overhead and collaboration fees = daily compensation). Salaried psychiatric NPs in my area are typically offered around $100,000-$130,000. This averages out to about $48-$62 per hour. Once you add in PTO and an allowance for CEs, malpractice insurance, and license renewals it would raise the value of your hourly rate by a few dollars.

So, which option is better? It depends on what matters most to you. My biggest piece of advice: KNOW YOUR VALUE! Research what insurance is reimbursing for services you provide and be sure you are getting appropriately compensated for the work you do. Many, many facilities and physicians are offering crazy low ball numbers to NPs and they keep doing this because WE KEEP ACCEPTING IT! Stand your ground. Recognize what you have to offer. Recognize the monetary value you bring to a practice. Don’t be afraid to negotiate. Yes, we are nurses because we love taking care of patients, we love educating, we love seeing our patients thrive, but those values do not conflict with being business savvy. YOU CAN BE BOTH!

Let me know in the comments how your negotiation went to get your NP job. Are you contracted or salaried? What do you like or dislike about the compensation structure of your current position? If you have any questions or suggestions for a future post please let me know! Thanks for joining!