Bill for Independent Nurse Practice in Mental Health

[Baller MD]

http://www.asahq.org/advocacy/fda-a...ctice-legislation-introduced-in-the-us-senate

"the legislation also includes provisions to allow “independent” practice for certain nurses, including Nurse Midwives, Clinical Nurse Specialists for mental health and Nurse Practitioners within the VA health system."

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[vistaril]

at least primary care physicians can make it up with volume. That's always a safety net they have. We don't have the same safety net.

 

[nitemagi]

The VA is already a mess in their clinical hierarchy.

 

[PikminOC]

allow the “independent” practice of certain Advance Practice Registered Nurses (APRNs) within the U.S. Department of Veterans Affairs (VA)...
ASA is pleased that S. 297 appropriately excludes nurse anesthetists. The legislation reflects a growing Congressional consensus that the surgical/anesthesia setting is a high-risk health care environment requiring physician involvement in care...

 

[PikminOC]

The VA is already a mess in their clinical hierarchy.

And a mess in their Admin hierarchy.
Folks, this is what single payor looks like, and it ain't pretty!

 

[Indodo]

Supply demand economics.

 

[MLT2MT2DO]

Wow with the combat medics...these are enlisted people without a degree of any sorts. They get basic emt in military training.

 

[F0nzie]

Psychiatrist, NP, RN... What's the difference. Mentally ill people just need someone to listen to them and say "there there..." Plus RNs spend more time with patients and are way nicer than NPs and Psychiatrists. The best part is there is no difference in outcomes either! +1 for the VA.

 

[wolfvgang22]

Wow with the combat medics...these are enlisted people without a degree of any sorts. They get basic emt in military training.

I agree, this is a bad joke. I have a few patients who are former combat medics, and not a single one of them has a clue about psychiatric medications, including the ones they take until I educate them.

This whole bill is scary. Thanks for bringing it to our attention. I hope the APA knows about this and is lobbying on our behalf to prevent the passage of this very dangerous bill. Rather than allow the grossly unqualified to potentially (and likely) harm our under-served veterans, the VA needs to get it's house in order and recruit real doctors, not fake made-up "docs". I can't believe they'd even consider doing this to veterans.
I get the feeling the VA is pulling out all the stops, to do what it can, but it has to keep safety in mind while doing that.

This other bill that was passed looks good, though. The Clay Hunt Bill from January 2015.
This one is good, too. (Veterans’ Access to Care through Choice, Accountability, and Transparency Act of 2014)

 

[F0nzie]

I can't believe they'd even consider doing this to veterans.

This.

 

[deleted480308]

The veterans deserve better...particularly when mental health is already a such an issue for the VA

 

[NickNaylor]

Let's see what happens when NPs start prescribing clozapine and send someone home with a mild fever home because "it's a cold."

 

[675015]

Let's see what happens when NPs start prescribing clozapine and send someone home with a mild fever home because "it's a cold."

What happens if a doctor prescribes clozapine and sends someone home with a mild fever because "its a cold"? I'm wouldn't worry about the obvious cases such as this but rather things that involve a little more intricacies. Certainly we have better arguments for physicians managing than knowing the side-effects of Clozaril.

 

[NickNaylor]

What happens if a doctor prescribes clozapine and sends someone home with a mild fever because "its a cold"? I'm wouldn't worry about the obvious cases such as this but rather things that involve a little more intricacies. Certainly we have better arguments for physicians managing than knowing the side-effects of Clozaril.

Of course there are, but in my scurry of writing a snarky post in ~30 seconds it was the best thing I could come up with.

 

[675015]

Of course there are, but in my scurry of writing a snarky post in ~30 seconds it was the best thing I could come up with.

Fair enough

 

[st2205]

Let's see what happens when NPs start prescribing clozapine and send someone home with a mild fever home because "it's a cold."

I doubt many NPs will prescribe Clozaril. I do think, however, they'll be more likely to start loading people up on a bunch of medications that are reinforcing people's maladaptive habits that they attribute to "my bipolar" and have the magic combos of one drug from every class.

The VA has pharmacists prescribe, as well, which is quite silly. A big problem in medicine is the idea of every problem being met with some type of intervention. I find as a general trend, the more experienced and specialized one is, the more conservative and confident they may be in not feeling obligated to "treat" every "problem." There are plenty exceptions to this, though. As a trend I see, in my experience, mid-levels over utilizing "problem = solution." So we continue to reinforce society's misconceptions by not having enough experience to confidently state why certain interventions are inappropriate.

 

[keifernny2]

They won't write for clozapine, but I do for see lots of scripts for Ritalin and adult-onset add in the future!


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[wolfvgang22]

I doubt many NPs will prescribe Clozaril. I do think, however, they'll be more likely to start loading people up on a bunch of medications that are reinforcing people's maladaptive habits that they attribute to "my bipolar" and have the magic combos of one drug from every class.

The VA has pharmacists prescribe, as well, which is quite silly. A big problem in medicine is the idea of every problem being met with some type of intervention. I find as a general trend, the more experienced and specialized one is, the more conservative and confident they may be in not feeling obligated to "treat" every "problem." There are plenty exceptions to this, though. As a trend I see, in my experience, mid-levels over utilizing "problem = solution." So we continue to reinforce society's misconceptions by not having enough experience to confidently state why certain interventions are inappropriate.

I have inherited some patients from pharmacists prescribing in the VA. I hate to say it, but they actually didn't mess up the veterans as much because they just did things like follow the Texas Medication Algorithm Project instead of prescribe everybody Xanax 1mg PO QID like one elder psychiatrist I replaced did.

I totally agree with you about the pressure to treat every problem. Every day at the VA I have to tell patients "I'm not going to give you a 6th psychiatric medication because it would actually be more likely to harm you than help you."

 

[Baller MD]

Let's see what happens when NPs start prescribing clozapine and send someone home with a mild fever home because "it's a cold."

They'll just refer them to you in that case.

 

[hamstergang]

I find as a general trend, the more experienced and specialized one is, the more conservative and confident they may be in not feeling obligated to "treat" every "problem."

Agreed. I see this happening in myself as I progress through training.

 

[vistaril]

I doubt many NPs will prescribe Clozaril. I do think, however, they'll be more likely to start loading people up on a bunch of medications that are reinforcing people's maladaptive habits that they attribute to "my bipolar" and have the magic combos of one drug from every class.

who does this now? Who incorrectly diagnoses Bipolar d/o and starts patients on 4 different drugs for it?

for the most part that is......psychiatrists. We can disagree about the ratio of benzo prescribing amongst pcps vs psychs, but there is no debate that the vast majority of patients on 4 different drugs for a bs bipolar dx were given them by psychiatrists. pcps may not know how to diagnose bipolar in a lot of cases either- but they almost never want to anyways.

I dont see any evidence that midlevels are more likely to dx patients with bipolar than psychiatrists. We already have thousands of psychiatrists who clearly do that.

 

[st2205]

who does this now? Who incorrectly diagnoses Bipolar d/o and starts patients on 4 different drugs for it?

for the most part that is......psychiatrists. We can disagree about the ratio of benzo prescribing amongst pcps vs psychs, but there is no debate that the vast majority of patients on 4 different drugs for a bs bipolar dx were given them by psychiatrists. pcps may not know how to diagnose bipolar in a lot of cases either- but they almost never want to anyways.

I dont see any evidence that midlevels are more likely to dx patients with bipolar than psychiatrists. We already have thousands of psychiatrists who clearly do that.

The next paragraph below the one you quoted does a good job qualifying that statement. There are certainly psychiatrist over diagnosing bipolar disorder and schizophrenia that have their patients on wacky combos. Way more than there should be. That said, I've never seen a patient being followed by a mid level who was being managed conservatively. This is my own limited personal experience, not data, but I believe I've already clarified that.

The bottom line is that most of medicine is practiced out a fear of litigation and public opinion. It's my opinion that this is the largest driving force between "problem, intervention" despite what's best for the patient. Lots of unnecessary imaging, tests, procedures, hospital admissions, medicines, etc. This is how we're treating healthcare anxiety at a societal level. In mental health we continue to do things that we know are of limited value because of societal expectation (i.e. keeping people in hospital because family doesn't think they're safe, when there's nothing more that a prolonged hospitalization will mitigate, or giving medications for the same reason). We're afraid that if something happens we will be blamed. Something may happen. People will commit suicide. They'll kill other people. People will have heart attacks. We always erroneously think medicine prevents this. When we reference how many people died on the VA waiting list, the underlying assumption is that if these people simply got into a primary care clinic that death would have somehow been averted. It's not realistic, but we feed it. Those with the most limited exposure will feel obligated to do what they're placed there to do -- "intervene." This is typically done with a medication for each problem, just to make sure we did everything we could, regardless what's best for the patient. Physicians do this all the time. In fact, it's more the rule than the exception. The problem I emphasize is the more we "need to address" medical problems by pushing for cursory competence, the more people will feel they can sling medications for each problem just as well as we can (and they do if that's how you practice, which most do). It's just poor practice, though. We complain about the letigious nature of medicine but don't recognize our own hand in it -- we're setting the standard of care by acquiescing to unreasonable expectation. Pushing midlevels to do the same thing is a surrender to this notion.

 

[milesed]

My concerns about this are driven only by my personal experience with ARNP's in psyc and one RN with nurse specialist credentials. Neither are allowed fully independent practice here.

The RN does a great job with therapy and pointing out symptoms that she feels would benefit from meds. That is where her experience with meds ends. There have been many med problems in our shared patients she has totally missed or labeled as something unrelated to meds. The ARNP's are very good at doing most of what I do, but they contact me DAILY with questions as they are constantly getting stuck on difficult (and sometimes easier) patient issues. Don't get me wrong, I love having ARNP's and feel that they fill a void in our practice where patients would otherwise wait forever to be seen w/o them here. We just make certain they are supervised and sign a collaborative agreement.

Questions I get constantly-

How do I deal with this abnormal lab?
What interactions should I be worried about here?
My app or computer program says___, is that correct?
Pt X has tried 8 antipsychotics, is now on 3 and still psychotic. What do I do?

 

[st2205]

Pt X has tried 8 antipsychotics, is now on 3 and still psychotic. What do I do?

My personal favorite.

 

[Indodo]

My concerns about this are driven only by my personal experience with ARNP's in psyc and one RN with nurse specialist credentials. Neither are allowed fully independent practice here.

The RN does a great job with therapy and pointing out symptoms that she feels would benefit from meds. That is where her experience with meds ends. There have been many med problems in our shared patients she has totally missed or labeled as something unrelated to meds. The ARNP's are very good at doing most of what I do, but they contact me DAILY with questions as they are constantly getting stuck on difficult (and sometimes easier) patient issues. Don't get me wrong, I love having ARNP's and feel that they fill a void in our practice where patients would otherwise wait forever to be seen w/o them here. We just make certain they are supervised and sign a collaborative agreement.

Questions I get constantly-

How do I deal with this abnormal lab?
What interactions should I be worried about here?
My app or computer program says___, is that correct?
Pt X has tried 8 antipsychotics, is now on 3 and still psychotic. What do I do?

Is this private practice, employed for a group or some type of government job?

 

[sunlioness]

Let's see what happens when NPs start prescribing clozapine and send someone home with a mild fever home because "it's a cold."

How many of you work with NPs? Because I do routinely and they are some of the most competent, humble, conservative, and effective clinicians. If anything the ones I've worked with are more cautious and deferential in their scope than they really need to be. And do more counseling than I tend to do too. I hope we hire more.

 

[Shikima]

How many of you work with NPs? Because I do routinely and they are some of the most competent, humble, and effective clinicians. If anything the ones I've worked with are more cautious and deferential in their scope than they really need to be. I hope we hire more.

I've seen a vast array of competency so far.

 

[NickNaylor]

How many of you work with NPs? Because I do routinely and they are some of the most competent, humble, conservative, and effective clinicians. If anything the ones I've worked with are more cautious and deferential in their scope than they really need to be. And do more counseling than I tend to do too. I hope we hire more.

I have worked with quite a few and the quality can be highly variable. Some are very competent. Others not so much. Some are completely clueless. I have no idea what to expect when working with any one individual APN.

 

[AcronymAllergy]

I doubt many NPs will prescribe Clozaril. I do think, however, they'll be more likely to start loading people up on a bunch of medications that are reinforcing people's maladaptive habits that they attribute to "my bipolar" and have the magic combos of one drug from every class.

The VA has pharmacists prescribe, as well, which is quite silly. A big problem in medicine is the idea of every problem being met with some type of intervention. I find as a general trend, the more experienced and specialized one is, the more conservative and confident they may be in not feeling obligated to "treat" every "problem." There are plenty exceptions to this, though. As a trend I see, in my experience, mid-levels over utilizing "problem = solution." So we continue to reinforce society's misconceptions by not having enough experience to confidently state why certain interventions are inappropriate.

+1

And beyond not necessarily having an appropriate solution for every problem is the concept that sometimes, the best solution for a particular problem is no intervention (at least on the part of the provider), or perhaps at least no medical intervention. Unfortunately, the way many systems are currently setup, patients aren't really primed to expect or accept and practitioners aren't always able or encouraged to provide a response of "let's wait and see" when it's appropriate.

 

[heyjack70]

How many of you work with NPs? Because I do routinely and they are some of the most competent, humble, conservative, and effective clinicians. If anything the ones I've worked with are more cautious and deferential in their scope than they really need to be. And do more counseling than I tend to do too. I hope we hire more.

What counseling training do they have? From what I've seen not much. I agree that NPs take more time with patients, but there is a difference between talking about the day and actual therapy/counseling.

 

[AnnoyedByFreud]

What counseling training do they have? From what I've seen not much. I agree that NPs take more time with patients, but there is a difference between talking about the day and actual therapy/counseling.

I'm a PMHNP student. We took four therapy classes (adult, child, group, family), taught by a mix of providers (psychologists, LCSWs - though this guy had a PhD, and ARNPs). We do therapy in our clinical training, though not to the extent of psychologists, obviously. Also, not sure what the hang up is over clozaril. The PMHNPs I work with prescribe it when appropriate, order the appropriate follow-up labs, etc. Now if someone can explain to me the pts we inherited from the retiring psychiatrist who are on 3+ neuroleptics and multiple benzos, that would be great...

 

[heyjack70]

I'm a PMHNP student. We took four therapy classes (adult, child, group, family), taught by a mix of providers (psychologists, LCSWs - though this guy had a PhD, and ARNPs). We do therapy in our clinical training, though not to the extent of psychologists, obviously. Also, not sure what the hang up is over clozaril. The PMHNPs I work with prescribe it when appropriate, order the appropriate follow-up labs, etc. Now if someone can explain to me the pts we inherited from the retiring psychiatrist who are on 3+ neuroleptics and multiple benzos, that would be great...

You don't do therapy to the extent of psychiatrists either. Some psychiatrists get more therapy training than psychologists.

 

[AnnoyedByFreud]

Sure, no argument there.

 

[strangeglove]

I've seen a vast array of competency so far.

I have to say that the one NP that I work with in a research setting is very thorough and is aware of the limitations of her training. At the same time, I've seen patients in my private practice who have been horribly misdiagnosed and placed on inappropriate meds by NP's in their own "private practices." I think, based on this limited sample, that NP's who accept the role of working under the supervision of physicians as part of a team tend to be competent, whereas those who are bucking to act like MD's and as a result are overreaching in their medical knowledge tend to cause problems.

 

[Shikima]

I have to say that the one NP that I work with in a research setting is very thorough and is aware of the limitations of her training. At the same time, I've seen patients in my private practice who have been horribly misdiagnosed and placed on inappropriate meds by NP's in their own "private practices." I think, based on this limited sample, that NP's who accept the role of working under the supervision of physicians as part of a team tend to be competent, whereas those who are bucking to act like MD's and as a result are overreaching in their medical knowledge tend to cause problems.

I received one Pt in PP who was on 6 different psych meds including 3mg of Klonopin and 90mg of Adderall daily.
le sigh

 

[notdeadyet]

I have worked with quite a few and the quality can be highly variable. Some are very competent. Others not so much. Some are completely clueless. I have no idea what to expect when working with any one individual Psychiatrist.

Also true.

 

[Zenman1]

You don't do therapy to the extent of psychiatrists either. Some psychiatrists get more therapy training than psychologists.

Name a medical school that does that.

 

[Zenman1]

who does this now? Who incorrectly diagnoses Bipolar d/o and starts patients on 4 different drugs for it?

for the most part that is......psychiatrists. We can disagree about the ratio of benzo prescribing amongst pcps vs psychs, but there is no debate that the vast majority of patients on 4 different drugs for a bs bipolar dx were given them by psychiatrists. pcps may not know how to diagnose bipolar in a lot of cases either- but they almost never want to anyways.

I dont see any evidence that midlevels are more likely to dx patients with bipolar than psychiatrists. We already have thousands of psychiatrists who clearly do that.

We have one hospital around here that we send Soldiers to and I swear they must own stock in Latuda. One discharged guy turned around and drove back to the hospital after a pharmacy told him he would have to get prior auth for Latuda. The hospital then gave him a script for risperidone. So when I saw his zombie self a short while later I told him since he was just pissed off due to an occupational problem, perhaps Prozac might be more appropriate since he also had OCD.

 

[heyjack70]

Name a medical school that does that.

Residency is actually where psychiatrists get trained in therapy. 4 years of clinical training after medical school.

 

[Shikima]

We have one hospital around here that we send Soldiers to and I swear they must own stock in Latuda. One discharged guy turned around and drove back to the hospital after a pharmacy told him he would have to get prior auth for Latuda. The hospital then gave him a script for risperidone. So when I saw his zombie self a short while later I told him since he was just pissed off due to an occupational problem, perhaps Prozac might be more appropriate since he also had OCD.

Or Zoloft.....

 

[Zenman1]

Or Zoloft.....

Yes, but I didn't plan on listing every med that might work….

 

[keifernny2]

I am a big fan of ARNPs and agree that those that work within their scope of practice do a great job.
I just wish we had a better way to ensure that private practice NPs were working within their scope.

The same problem exists with physicians, however MOC was supposedly created to address this.

On another note, some ARNPs are "abused" by physicians and clinics for their prescribing privileges and don't have the same threshold to walk out and say "enough is enough" when asked by clinic admin to practice unethically. I see this as a major problem (at least in the rural area I'm in).
I've never met an ARNP who set out to work in a pill mill, but it sure does seem to happen a lot.



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[Zenman1]

Residency is actually where psychiatrists get trained in therapy. 4 years of clinical training after medical school.

I'm aware of that but I was under the impression psychiatric training had more bio focus now than therapy and in the past even required students go through their own therapy.

 

[gabafan]

I've seen a vast array of competency so far.

As an NP, I think this is true. The level of rigor in NP programs varies widely, and I think the variation in knowledge level of graduates shows this. However not all NP's lack even basic knowledge about prescribing, or overmedicate patients. I have sent many patient out the door without Xanax (some in tears), and I have yet to be convinced that I should medicate "ADHD" with stimulants in a an adult who was not diagnosed and treated for this condition as a child.

Take a look at this med list I came across in a patient being managed by a psychiatrist: Adderall 20 QID, Xanax 1 QID, Phenobarbital 120 at HS for sleep, and Thorazine 50 QD. Pt was from out of the area and ended up in out ER w/ manic sx. The patient reported being dx w/ bipolar d/o and ADHD. I couldn't believe it... but a phone call to his psychiatrist confirmed the medication list. His rationale for using this unusual cocktail? The pt had been "stable" on these medications for years! I looked up the credentials of the psychiatrist out of curiosity... he went to Harvard.

 

[Zenman1]

I have yet to be convinced that I should medicate "ADHD" with stimulants in a an adult who was not diagnosed and treated for this condition as a child.

Think about this carefully. Just because an adult was not diagnosed and treated as a child only means that they were not diagnosed and treated as a child.

 

[erg923]

I have yet to be convinced that I should medicate "ADHD" with stimulants in a an adult who was not diagnosed and treated for this condition as a child.

Take a look at this med list I came across in a patient being managed by a psychiatrist: Adderall 20 QID, Xanax 1 QID, Phenobarbital 120 at HS for sleep, and Thorazine 50 QD. Pt was from out of the area and ended up in out ER w/ manic sx. The patient reported being dx w/ bipolar d/o and ADHD. I couldn't believe it... but a phone call to his psychiatrist confirmed the medication list. His rationale for using this unusual cocktail? The pt had been "stable" on these medications for years! I looked up the credentials of the psychiatrist out of curiosity... he went to Harvard.

That might be one of the dumbest things I've ever heard. I hope you would at least consult them to someone who would bother to work up the differentials properly....

 

[keifernny2]

Think about this carefully. Just because an adult was not diagnosed and treated as a child only means that they were not diagnosed and treated as a child.

Not to hijack the thread into an ADHD thread, but there is 1 more very important thing that it means.-

It means that they did not show significant enough impairment as a child that anyone saw fit to refer them for diagnosis or to ensure that they followed through.

 

[heyjack70]

Not to hijack the thread into an ADHD thread, but there is 1 more very important thing that it means.-

It means that they did not show significant enough impairment as a child that anyone saw fit to refer them for diagnosis or to ensure that they followed through.

Or nobody cared or knew what to look for and wrote them off as a trouble maker.

 

[jl lin]

The real issue is that there not enough psychiatrists in certain areas. Or there are not enough willing to work outside of fee for service. So, in certain areas, Pschiatric NP is on the demand.

There are many areas that are near major cities where in those subburbs, you can't find a psychiatrist that will take the pt's insurance, and where people can't afford $200-$300+ per visit. These pts need frequent visits for monitoring meds and other issues. It's quite sad.

People have to do something totally whack or attempt suicide before they will be able to find decent treatment. Meanwhile, mental hospitals are releasing more chronic pts into the communities d/t costs. These folks become homeless and or become a danger to others or themselves. It's kind of a serious problem. And I think with push for more legalization of MJ, you are gonna see more kids self-medicating and more problems.

 

[AnnoyedByFreud]

As an NP, I think this is true. The level of rigor in NP programs varies widely, and I think the variation in knowledge level of graduates shows this. However not all NP's lack even basic knowledge about prescribing, or overmedicate patients. I have sent many patient out the door without Xanax (some in tears), and I have yet to be convinced that I should medicate "ADHD" with stimulants in a an adult who was not diagnosed and treated for this condition as a child.

Take a look at this med list I came across in a patient being managed by a psychiatrist: Adderall 20 QID, Xanax 1 QID, Phenobarbital 120 at HS for sleep, and Thorazine 50 QD. Pt was from out of the area and ended up in out ER w/ manic sx. The patient reported being dx w/ bipolar d/o and ADHD. I couldn't believe it... but a phone call to his psychiatrist confirmed the medication list. His rationale for using this unusual cocktail? The pt had been "stable" on these medications for years! I looked up the credentials of the psychiatrist out of curiosity... he went to Harvard.

This strikes me as odd. I understand wanting to be careful of addicts/med seekers, however, adult ADHD is a real condition and some people need stimulants to properly treat it. Not everyone is accurately diagnosed w/ADHD in childhood. Many kids slip through the cracks and struggle as adults. I'll step off my soapbox...