patient load and frequency of service

[erg923]

In your opnion:

1. What is a "full" patient load for a typical full-time therapist?
2. Do you think monthly therapy, sans those in "maintenence" type phases of treatment, is appopriate care?

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[smalltownpsych]

Those are good questions that came up at our monthly department meeting a couple of days ago. I am not even sure how to count my patient load at this point. I have 40 appointment hours blocked out and try to keep those all filled since I only make money when I am billing. I am thinking that I am managing about 60-70 patients total. Severity and complexity of the cases plays a role in what I can manage effectively, too. About 2/3 of my patients at any given time are in the middle stage to termination phase of treatment and that is less demanding than the early stages.

I don't think that once a month is effective for early stages of treatment. I have some that I don't see for a few weeks after their initial visit because of scheduling and it is really hard to pick up where we left off in any way. I do have some patients that travel a long way and every two weeks is more practical and that works so long as they are high-functioning. I would put it this way to anyone saying that once a month would suffice. First, patients come to us because they are suffering, how can I ethically delay their treatment and prolong their suffering? Second, most of the research on empirically validated treatments is on weekly therapy, if I deviate to much from that will it even work? There might actually be some research on this second point.

Good luck with advocating for effective care for your patients and yourself. Welcome to the business and politics of healthcare where we will always be getting pressure to do more work for less money at the cost of effective treatment.

 

[testifeye]

I've been struggling with this issue in my current workplace. I work in a PTSD clinic in VA where I feel that I have a duty to provide a meaningful dose (e.g., frequency, # of sessions,, evidence-based content) of treatment to patients. Unfortunately, we get two intakes per week, and those folks are our patients regardless of our remaining case load.

I fantasize about the idea of being able to say I'm "full," but such a thing just doesn't exist in my system, and I don't think we are the exception.

In my particular context, I don't think monthly check-ins constitute therapy, especially because they essentially promote a cycle of avoidance, perpetuating and exacerbating PTSD. I do think that check-ins can be useful in some circumstances, such as: limited number of "booster sessions" following treatment completion, and/or sessions analogous to primary care "checkups." There are some severe patients that benefit from occasional check-ins which prevent costly inpatient hospitalizations.

 

[erg923]

The general mental health therpaists in my clinic have patient loads in the 150 range. They are, generally, seeing acutely distressed individuals every 4 weeks, and in some case every 6 weeks. I do not view this as adaquate or appopriate. My clinical duties (60%) are in primary care psych, and am seeing people every two weeks, which is appopriate given the mild pathology/distress and/or high functioning level of my patients.

This problem has become exponentially worse in the past 12 month. We have been empaneling 70 new patients a month in this Primary care clinic for over a year now. Yet they have not hired more therapists. Admin does not seem responsive to this need, and I can't figure out why given our recent press. I have talked to the therapists about being mre hardline about "discharging" the more mild people or pretty much disallowing purely "supportive psychotherapy" for the time being, but to no avail.

 

[Therapist4Chnge]

How do your #'s compare to neighboring Vas?

I'd want to arm myself w. data. I'm not sure if you can get the new admission #'s for the past 3 years, but that could be very helpful. I'm not sure what the model is these days in the VA (e.g. focused on individual tx vs. group tx, time limited v. LT cases etc) During my year in the VA there was a big push to get Veterans into groups to show that they are getting "into the system". I wasn't wild about group tx being the focus, but if we got them to groups, then we could triage the acute cases via individual tx.

 

[testifeye]

It is possible that you and administration do not share the same goal. While of course administration may have the intent of serving the most patients with available resources, sometimes administrators don't understand concepts such as "dose of treatment." They could be shooting themselves in the foot: by giving more patients less care, they retain X amount of people in the system who may have discharged if they had gotten a meaningful dose of treatment. Then the system gets bloated with more and more people, everyone wants relief from their suffering, and the delay between their mental health contacts gets wider and wider. This isn't just an issue of resource allocation of course, but also of ethical provision of care.

Most hospital systems have an ethics consultant or ombudsman. Sometimes this service can be anonymous, but sometimes it's not. There are several benefits to this: a) providers who object to the current system, if they voice their objections to supervisors as well as consult ethics officers they reduce their own liability "going along with" something they think is wrong; b) there is a potential gain of strength to the argument to the administration that something needs to change.

Another avenue to consider is measuring outcomes. Often our systems are excellent at measuring *access* but not outcomes. Prove, with data, that weekly contact for limited durations improves outcomes and facilitates better use of hospital resources. This isn't a quick solution, but sometimes data has more power than our informed professional opinions.

 

[erg923]

How do your #'s compare to neighboring Vas?

I'd want to arm myself w. data. I'm not sure if you can get the new admission #'s for the past 3 years, but that could be very helpful. I'm not sure what the model is these days in the VA (e.g. focused on individual tx vs. group tx, time limited v. LT cases etc) During my year in the VA there was a big push to get Veterans into groups to show that they are getting "into the system". I wasn't wild about group tx being the focus, but if we got them to groups, then we could triage the acute cases via individual tx.

I am actually not part of the general mental health service here, so I am not clued in. I just know they are busy as ****.

We do groups here too- And I do one in primary care for pain. Doesn't have too much of a dent on the demand, overall.

They could be shooting themselves in the foot: by giving more patients less care, they retain X amount of people in the system who may have discharged if they had gotten a meaningful dose of treatment. Then the system gets bloated with more and more people, everyone wants relief from their suffering, and the delay between their mental health contacts gets wider and wider.

This is EXACTLY what is happening.

 

[Therapist4Chnge]

An analysis of re-admission rates is also worth considering….as undertreated/untreated MH can often be the catalyst for exacerbation of one or more chronic medical conditions, which land the person in the ED and cost tens of thousands of dollars to address.

 

[smalltownpsych]

The general mental health therpaists in my clinic have patient loads in the 150 range. They are, generally, seeing acutely distressed individuals every 4 weeks, and in some case every 6 weeks. I do not view this as adaquate or appopriate. My clinical duties (60%) are in primary care psych, and am seeing people every two weeks, which is appopriate given the mild pathology/distress and/or high functioning level of my patients.

This problem has become exponentially worse in the past 12 month. We have been empaneling 70 new patients a month in this Primary care clinic for over a year now. Yet they have not hired more therapists. Admin does not seem responsive to this need, and I can't figure out why given our recent press. I have talked to the therapists about being mre hardline about "discharging" the more mild people or pretty much disallowing purely "supportive psychotherapy" for the time being, but to no avail.

Admin is probably just responding to the narrow perspective of "not making patients wait" that seems to be the recent political football.

 

[Rivi]

In your opnion:

1. What is a "full" patient load for a typical full-time therapist?
2. Do you think monthly therapy, sans those in "maintenence" type phases of treatment, is appopriate care?

1. I am on post-doc now, so I don't have a lot of firsthand knowledge, but from what I have observed:

Per week:
College Counseling Centers: 15 individual sessions, 1-2 groups, 1-2 outreach presentations, 2-3 (?) intakes, and a few hours dedicated to supervising practicum students and/or interns

The colleagues I worked with in other settings weren't "full time therapists" per say, and did a bit of everything, including assessment and consultation. I know the state hospital setting required 7ish groups per week, but didn't have any other "requirements" per week.

2. Not really. Aside from booster/maintenance sessions, biweekly is the least amount of frequency I would put between sessions on a regular basis with someone with active issues. 3-4 weeks between the average session makes it hard to retain and build on the information learned in previous sessions.

 

[erg923]

1. I am on post-doc now, so I don't have a lot of firsthand knowledge, but from what I have observed:

Per week:
College Counseling Centers: 15 individual sessions, 1-2 groups, 1-2 outreach presentations, 2-3 (?) intakes, and a few hours dedicated to supervising practicum students and/or interns

The colleagues I worked with in other settings weren't "full time therapists" per say, and did a bit of everything, including assessment and consultation. I know the state hospital setting required 7ish groups per week, but didn't have any other "requirements" per week.

2. Not really. Aside from booster/maintenance sessions, biweekly is the least amount of frequency I would put between sessions on a regular basis with someone with active issues. 3-4 weeks between the average session makes it hard to retain and build on the information learned in previous sessions.

The therapists have some designated EBT slots for running manualized stuff (ACT, PE, CBT-I, CPT, IT for depression, etc.) but that only like a quarter of their therapy slots. They have two intake slot per week. So, right now, only people who can be pinned into these protocols are getting traditional weekly therapy from them. And I misspoke earlier, one the social worker therapists here has a load of 200, with about 170 of them active right now!

 

[Balmoral]

I work in post-acute rehab that has a residential branch so my contact frequencies can vary. My total caseload is approximately 5-8 IP and 15-20 OP. I also perform at least 1 comprehensive eval a week.

Productivity expectations at my facility is around 65% although I know other disciplines are closer to 75%.

 

[AcronymAllergy]

Sigh, those productivity expectations sound quite realistic. We're in the 85-90% range. Exciting stuff.

As for my caseload, I'm essentially all outpatient assessment, so it'll be a bit different for me than other folks. It typically works out to 4 full evals + 3-4 feedback sessions/week.

 

[Therapist4Chnge]

I have a 30hr/wk commitment to cover in-pt consults/evals, rounds, supervise, teach didactics, etc.
My out-pt is generally 6-10 full evals per month (1.5-2.5 cases per wk).

I try and keep it around 40hr/wk, though some weeks it's 35hrs and other weeks it's 50hrs. I enjoy traveling, so I average at least 1 long weekend per month, so on those weeks I'll do 35hrs over 3-4 days so my coverage needs are minimal.

 

[researchgirl]

I know of at least one VA that created an EBP Team. All therapists on this team ONLY do EBPs, so their caseloads are all somewhere in the 15 to 25 patient range, depending on their level (e.g. LPC, MSW, Psychologist) and their other responsibilities. This seems to work really well for patients who would benefit from time-limited EBP treatment and who can commit to weekly therapy sessions. However, for patients with more complex presentations, they have to be seen on other MH teams, and some of those teams are significantly overburdened and unable to do regular weekly therapy.

I personally do not believe that monthly therapy with the average client is appropriate care. I do not believe I could effectively treat depression, an anxiety disorder, etc., with monthly sessions. So then the question becomes, is it better to provide sub optimal care for everyone, or is it better to provide optimal care for some while making others sit on a wait list. I prefer the latter, but I come with many biases.

The other issue we've run into at the aforementioned VA is patients who would benefit from an EBP, but cannot commit to regular weekly treatment. Do you try to give them a treatment at a dose that may not be effective (e.g. monthly) or do you tell them to come back when they are able to commit to treatment in a format you deem to be effective? (I realize this point is fairly off-topic from the original question, but still interesting to me).

 

[Balmoral]

Sigh, those productivity expectations sound quite realistic. We're in the 85-90% range. Exciting stuff.

As for my caseload, I'm essentially all outpatient assessment, so it'll be a bit different for me than other folks. It typically works out to 4 full evals + 3-4 feedback sessions/week.

I'm fortunate that pyschologists are held in high regard in my company. I think a large part of it is leadership involvement. We facilitate team meetings, provide treatment direction, and are the first contact for physiatrists and psychologists. don't get me wrong, I put enough "non-productive" time (almost twice as much as productive so I'm pulling 60-70 hours/week) but it's job security.

 

[erg923]

You can bill for almost anything if you do it right. Or at least document/code towards rvu

 

[CBTFTW]

The other issue we've run into at the aforementioned VA is patients who would benefit from an EBP, but cannot commit to regular weekly treatment. Do you try to give them a treatment at a dose that may not be effective (e.g. monthly) or do you tell them to come back when they are able to commit to treatment in a format you deem to be effective? (I realize this point is fairly off-topic from the original question, but still interesting to me).

I'm on internship at a VA right now, so limited info, but this is exactly the dilemma I see our team run into where I am. Many of our Veterans have busy lives, especially those who are younger and are working or in school. They want help, they can benefit from the help, but they just can't do weekly session, especially during work hours. This feels like a huge ethical issue -- do we give them some help, knowing it may not do much good (and may be iatrogenic if they develop beliefs about therapy not working), or do we give them no help beyond crisis intervention? Our team doesn't do much supportive therapy, so that's mostly out.

 

[smalltownpsych]

You can bill for almost anything if you do it right. Or at least document/code towards rvu

I'm a bit confused about this statement. I feel pretty limited in what I can code for billing to direct provision of services. The one thing that eats into my production the most is coordination of care with other team members or even phone calls to family or outside professionals.

 

[smalltownpsych]

Oh and I just showed this thread to our PMHNP who asked the question about caseload in our meeting. She stated that she saw 1850 patients last year and that two to three months is the wait time and she has ethical dilemma regarding starting a medication and not being able to schedule a follow-up for about two to three weeks. She said that she feels more comfortable if they are seeing myself for ongoing therapy, but I am not sure that really suffices as my advice to them is usually to stay pat until they see her again and i have limited training or knowledge of possible adverse effects to watch for.

 

[erg923]

My intervention notes take 5-7 minutes each. Sometimes less.

Assessment report writing is folded into 96101 or 96118. Phone calls with patients with any clinical content can be billed, tx teams counts towards my productivity if we code it right. Prac student labor counts towards my productivity. Records reviews can be coded productivity (90885), although not sure that's a billable code.

 

[smalltownpsych]

My intervention notes take 5-7 minutes each. Sometimes less.

Assessment report writing is folded into 96101 or 96118. Phone calls with patients with any clinical content can be billed, tx teams counts towards my productivity if we code it right. Prac student labor counts towards my productivity. Records reviews can be coded productivity (90885), although not sure that's a billable code.

Where I work if it is not a billable code then it doesn't count towards my RVUs so the only non-patient contact that counts is assessment report writing, scoring, and interpretation. My understanding is that medicare decided a long time ago that they wouldn't pay for phone calls and that becomes the standard for all insurances.

 

[erg923]

My understanding is that medicare decided a long time ago that they wouldn't pay for phone calls and that becomes the standard for all insurances.

I always code that as 98966. Its .38 RVUs. 98967 if it goes longer than 10 minutes. .74 RVUs.

 

[smalltownpsych]

I always code that as 98966. Its .38 RVUs. 98967 if it goes longer than 10 minutes. .74 RVUs.

Not reimbursed by insurance carriers so the hospital won't even bill it. In the scheme of things, it probably wouldn't add up to that much additional money by the end of the month. The challenge is more about finding the time to make the calls when the bulk of my income is determined from face to face contact. I used to have a documentation hour scheduled for that at another facility but in the private setting, that would cost me and the hospital too much. My documentation, phone calls, and collaboration these days all come during no shows. It does make for a more hectic pace and some days I wonder if I am pushing it too hard. I am glad for the upcoming holiday and will leave it all behind for the next five days. Only four sessions this a.m. and then I am jetting out of town!

 

[IT514]

The contract currently in the works for me includes a base salary that is set at the national average for my subspecialty and level of experience, with a bonus that is 20% RVU based and the rest comprised of factors agreed upon by my supervisor and dept chair. These other factors include phone calls to or from patients, phone calls or other communication to the referral source, teaching and reasearch. Bonuses are guaranteed the first year and from what I've heard, 95% of ppl in the department including those in my subspecialty (neuro) get their bonus.

While I havent worked under this type of contract yet, it seems a good way to those address nonbillable things that are nonetheless valuable to the hospital and essential to patient care. Staff seem to be happy with this arrangment from what I have heard.

 

[Therapist4Chnge]

I'm fortunate to have a great admin staff to handle most of the phone calls, scheduling, and back and forth with pts and insurance companies. However, I still get pinched on non-billable time handling in-pt problems that are not billable (or not going to pay anything…medicaid, no insurance, etc) and out-pt time handling billing problems/audits….which are on the rise.

 

[smalltownpsych]

I'm fortunate to have a great admin staff to handle most of the phone calls, scheduling, and back and forth with pts and insurance companies. However, I still get pinched on non-billable time handling in-pt problems that are not billable (or not going to pay anything…medicaid, no insurance, etc) and out-pt time handling billing problems/audits….which are on the rise.

Great admin staff is essential to a smooth running clinic. Our clinic runs extremely well. The rest of the hospital? Not always so good. I just found out that about half of my billable work in the long-term care was not being billed for the past six months. Fortunately, that was not a big number, but every bit counts.

 

[Sanman]

It really depends on how your RVU system is setup. I work in the Non-VA world in sub-acute rehab and long-term care. My pt load likely exceeds 200 at this point with at leat 80% active. However, much of my job is assessment and many on the long-term care rts are really on maintenance an monitoring sx for the Psych NP than comprehensive tx. Covering multiple facilities, the problem happens when you have 5+ intakes in a day and with multiple facilities to cover, it really varies. I'm not going to say that the level of care is not compromised when it is (pt number 9 never gets the same care as number 1). The larger issue is that psychology as whole is compromised because of low reimbursement. I see up to 16 pts/day and have to bill the equivalent of 10-12 90834s to make my RVUs for most of the companies I have worked for in this area. Assessment makes the goal easier, but this is the way it is going in the insrance world. Even my old outpt office expected 9-11 90834/ day to justify salary or make a comfortable living on productivity. As for phone calls and non-billables, I often leave it to the Psych NPs I work with as they often see only 4-6 pts per day and have the time. Really, there needs to be a recalcuation on reimbursement to improve the quality of care.