New to CMHC: scheduling questions and no shows

[psychdesoleil]

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Hello all! I am working at a CMHC. First job out of residency so still getting adjusted. I'm wondering how often those of you in similar jobs are scheduling follow up visits. It seems like the culture here is to have people back every two months but I have a lot of decompensated patients and feel like they should be seen more often. In residency I would see people back in a month and sometimes even sooner if needed. I think even people with moderate to severe depression should be seen more than every 8 weeks until they are stabilized. Does that seem unreasonable? As it is I only have 15 minutes for follow-ups so I am trying to do as much as I can in the time I have. The only way I can fit them in sooner than 8 weeks is to double book or come in early/leave late because my schedule is so full. I don't want this to become a pattern. Is the problem that they have not left any openings and just filled up my schedule? Maybe things will get easier when I have worked through most of my intakes?

Also, how to you handle refills for people who no show? The last provider I am replacing left abruptly so a lot of the patients have been waiting to see me since the spring and have just been getting bridge prescriptions written by other providers at the clinic since then. I'm seeing all of the transferred patients as new visits and my schedule is all booked up so if they no show to an initial 45 minute visit they might get scheduled for 2 or 3 months down the line. The problem is they all call for refills. They have been patients at the clinic for some time and have been getting endless refills so they feel they are entitled but I've never met or evaluated them. I don't mind for stable people getting appropriate medications but many are on things I wouldn't normally prescribe or they haven't had a diagnostic eval since the 1990s and their diagnosis doesn't at all correlate with the things they are prescribed.

Any suggestions would be greatly appreciated! Thanks!

 

[wolfvgang22]

Your follow up time between appointments seems reasonable, especially as you dont know these patients. Don't overbook people unless it is urgent for the patient, otherwise you will burn out quickly. Once you know them you can see them according to need/severity. This will take a few months. I have some I see monthly, some I see every 2, 3, 4, or 6 months. I have a few I see more frequently if they aren't very stable, but if I have to see someone weekly and I'm NOT doing therapy, then the patient may be too unstable for out patient care.

I wonder if you are being over worked. How many are you seeing per day?

I try to prescribe patients enough meds to last until they see me next, no more. This prevents no shows and encourages safe follow up and reduces diversion and abuse of medication. When I meet the patient the first time, I nicely let them know that I dont give endless refills, and if he/she no-shows or cancels I will fill just enough to last until the next appointment ONE time. No appointment scheduled means no refill. After that, they have to come see me before I'll prescribe again. I say this is for safe prescribing. If they don't like that, they are welcome to see a different psychiatrist. The patient can't say I never told them that this is my policy, because I tell them up front.

Don't prescribe anything dangerous, or tons of benzos obviously, just because someone else did. Things do get easier once you know the patients. If you think you need to do a diagnostic eval, do it. Don't ever apologize or back down for having a high standard of care for your patients.

 

[dl2dp2]

You are clinically absolutely correct. This is a "systems" issue and needs to be resolved at that level. I would not back down from scheduling the patients exactly the way you want to, and if other staff give you push back, go to the clinical director.

Second scenario is again I would prioritize protecting your own liability first. I would never write a prescription I don't feel that I can justify in the court of law if an adverse event occurs. Patient no-show is not a reason to compromise clinical care. Just because patients demand things doesn't mean that you would kowtow to their needs. If you haven't seen the patient, and haven't written a prescription, it's not your patient, so if something goes wrong with the patient, it's not your problem. It may be the clinic's problem, but that's a separate issue.

I'm assuming you didn't work at a CMHC in residency, but these are basically standard issues at every single one of the around the country. There's a reason why people don't stay long at these jobs. The harder you try to stretch yourself like a rubber band the worse off everyone is. Instead of trying to work harder than you should, you should aim to provide optimal care for the limited case load that you can handle. If they are understaffed, they should get more money to staff, and that's a separate issue that you shouldn't be dealing with.

 

[psychdesoleil]

Thank you so much for your replies. I did work in a CMHC in residency but I didn't have a big enough case load to have an issue with scheduling. I'm seeing between 14 and 18 patients a day right now between intakes and follow ups and there are usually some no shows or cancelations. The doctors who have a full case load and aren't seeing new patients see over 20 patients a day since they are seeing a patient every 15 minutes. I don't so much have a problem with the volume with the fact that I don't have room to see patient's back soon enough because they have me booked solid from now till eternity. I imagined being a new provider that I would be building my caseload from scratch so I would have openings that would correlate with the amount of intakes I was seeing, which would eventually drop over time. Instead I was also given the case load from someone who left unexpectedly so I am already full for months down the road. I did talk to them about blocking off a half hour once a week to be used for people who need more urgent follow up so I'm not overbooking so I'm happy about that. I think it's definitely a "systems issue" but I'm glad to hear that I'm not the only one who is feeling like this is a problem since my colleagues give off the impression that they are fine with the current system and think I am working too hard. I have heard on more than one occasion when asking for clarification from my colleagues on how to get something done around here things like "let the primary care doctor/pharmacist worry about that" and "don't get too involved."For example, if patient's don't bring in an up to date med list I will call the pharmacy and get one, which happens like 10 times a day and takes up too much time but I don't feel comfortable prescribing a new medicine when they only information I have is that the patient has a "heart problem and a kidney problem or something" and takes "a blue pill and two orange pills." I asked a co worker how they are handling this and they said they ask the person to bring it in next time (aka 2 months from now) or they say the pharmacist will call if there are interactions. I could understand if I were stretching myself trying to rescue people but things like having an accurate up to date med list, AIMS testing, speaking to people's guardians, getting old records etc.. seem like standard of care issues not me being overzealous. I think it was emphasized in my training that all of these things are the psychiatrist's issue. Do you think its possible to get these things done in this setting and not burn out?

 

[dl2dp2]

I'm seeing between 14 and 18 patients a day right now between intakes and follow ups and there are usually some no shows or cancelations.

This is really a bit too much...I'm assuming though there's no way they'll drop your caseload. Also, even for Medicaid, this isn't necessary for optimal billing, as long as they do both 99213 and 90833. If you work for a state clinic, it's funded by a block grant, so it doesn't even matter how many people you see.

I don't so much have a problem with the volume with the fact that I don't have room to see patient's back soon enough because they have me booked solid from now till eternity.

You should tell admin to cancel appointments that are less urgent. Do what is clinically the right thing.

I imagined being a new provider that I would be building my caseload from scratch so I would have openings that would correlate with the amount of intakes I was seeing, which would eventually drop over time. Instead I was also given the case load from someone who left unexpectedly so I am already full for months down the road.

This is not uncommon. In fact I would say this is pretty much the only reason CMHC hires new people.

I did talk to them about blocking off a half hour once a week to be used for people who need more urgent follow up so I'm not overbooking so I'm happy about that.

This is effective, although I would be careful, because that half hour could stretch into a random walk-in clinic that extends your work day to an impossible length.

For example, if patient's don't bring in an up to date med list I will call the pharmacy and get one, which happens like 10 times a day and takes up too much time but I don't feel comfortable prescribing a new medicine when they only information I have is that the patient has a "heart problem and a kidney problem or something" and takes "a blue pill and two orange pills." I asked a co worker how they are handling this and they said they ask the person to bring it in next time (aka 2 months from now) or they say the pharmacist will call if there are interactions. I could understand if I were stretching myself trying to rescue people but things like having an accurate up to date med list, AIMS testing, speaking to people's guardians, getting old records etc.. seem like standard of care issues not me being overzealous. I think it was emphasized in my training that all of these things are the psychiatrist's issue. Do you think its possible to get these things done in this setting and not burn out?

You can get these things done, but you'll need to limit your case load. You obviously can't get it all done in 15 min. This is what 90836/99214/99215 is for (i.e. "coordination of care").

My experience in the CMHC setting suggests that in order to have a good experience, you need to have a mentality that everything has to be extremely controlled and circumscribed. Figure out what is your comfort level is, and be extremely strict about the frame. If you are a push over people WILL push more work on you (and this happen more to women than to men, in my experience), and you'll invariably burn out.

 

[smalltownpsych]

Some of the issues that you are bringing up sound like poor case management. If you allow that to happen, it will continue. Make it clear what your expectations are and they will eventually adjust and get you the required information so that you can do your job well. It might help the other docs too. The people in community mental health deserve quality care and they are getting a significant amount of funding to provide it so don't allow administration and organizational problems dictate ineffective care.

 

[wolfvgang22]

The reason your colleagues can see 20 patients a day and not work insane hours is either because the patients don't really need a psychiatrist and aren't that sick, or they are providing very minimal care.
I agree, you have to be strict, circumscribed, and all business about your time from the very beginning. There are lots of psych positions and opportunities like starting your own practice out there. You know it, they know it. That is your leverage. Don't be a jerk about it, but don't get walked on either.

 

[psychdesoleil]

I think being more strict about setting limits will help a lot. I can definitely see where it would be easy to take on more and more but its true that ultimately that wont result in better care either. I really appreciate the feedback. Its kind of isolating leaving residency and great to have this community for advice!

 

[Doctor Bagel]

Thank you so much for your replies. I did work in a CMHC in residency but I didn't have a big enough case load to have an issue with scheduling. I'm seeing between 14 and 18 patients a day right now between intakes and follow ups and there are usually some no shows or cancelations. The doctors who have a full case load and aren't seeing new patients see over 20 patients a day since they are seeing a patient every 15 minutes. I don't so much have a problem with the volume with the fact that I don't have room to see patient's back soon enough because they have me booked solid from now till eternity. I imagined being a new provider that I would be building my caseload from scratch so I would have openings that would correlate with the amount of intakes I was seeing, which would eventually drop over time. Instead I was also given the case load from someone who left unexpectedly so I am already full for months down the road. I did talk to them about blocking off a half hour once a week to be used for people who need more urgent follow up so I'm not overbooking so I'm happy about that. I think it's definitely a "systems issue" but I'm glad to hear that I'm not the only one who is feeling like this is a problem since my colleagues give off the impression that they are fine with the current system and think I am working too hard. I have heard on more than one occasion when asking for clarification from my colleagues on how to get something done around here things like "let the primary care doctor/pharmacist worry about that" and "don't get too involved."For example, if patient's don't bring in an up to date med list I will call the pharmacy and get one, which happens like 10 times a day and takes up too much time but I don't feel comfortable prescribing a new medicine when they only information I have is that the patient has a "heart problem and a kidney problem or something" and takes "a blue pill and two orange pills." I asked a co worker how they are handling this and they said they ask the person to bring it in next time (aka 2 months from now) or they say the pharmacist will call if there are interactions. I could understand if I were stretching myself trying to rescue people but things like having an accurate up to date med list, AIMS testing, speaking to people's guardians, getting old records etc.. seem like standard of care issues not me being overzealous. I think it was emphasized in my training that all of these things are the psychiatrist's issue. Do you think its possible to get these things done in this setting and not burn out?

15 minutes appointments can only work when other people do all these things for you. I'm guessing they also expect you to complete your documentation within the appointment time as well (or yes, stay late documenting). Or yeah, for patients who don't really need to be seen and could be handled via chart review or other contact (harder to get paid for that though). Anyway, it sounds miserable. At my community job, we had 30 minute follow ups and 90 minutes for new intakes. We also had a care coordinator who would track down records for us, call the pharmacy, etc.. Be sure to use those other resources if available. If not, that's a big issue.

 

[F0nzie]

At one point I was seeing over 25 patients a day because of this problem. The chief medical officer recently stepped in and cut my caseload in half and capped my schedule to no more than 12 patients a day. He also recruited another psychiatrist and an NP. I am very thankful.

 

[keifernny2]

Another option is to expand your hours (and make sure you get paid for it, of course). If you do 3-4 months at 50 hr weeks it may help the backlog of pts, as long as you're willing to do the extra work. CMHCs are often used to paying hourly wages and unless they are trying to take advantage of you should be willing to negotiate extra pay for extra billable hours.

Also, it is my opinion that any physician with 4 pts per hour deserves to have a nurse assigned to handle those phone calls / med lists 🙂 , though I've not always been able to get clinic managers to agree.

 

[psychdesoleil]

I will look into the expanded hours. I think the backlog of patients is a temporary problem so that would help. I definitely need a nurse or care coordinator. I'm surprised that the other doctors have been able to carry on as long as they have without those support services in such a busy clinic. There are nurses but they are primarily giving injections and doing med management groups. They are not assigned to any of the providers. I do all my own refills, prior authorizations, paperwork, collateral contacts, returning calls from patients about questions, etc..All the patients have a therapist but they aren't responsible for those type of care coordination duties.

 

[milesed]

They really need to get you some help if you have to run PA's, make all return calls, etc. It's cheap to hire a RN or even a LPN to do this and the time it would free up for you could be filled with income producing visits. Many places like this don't want it that way, but are understaffed and can't easily fill the positions. Are they looking for more MD or ARNP's?

One problem with giving you lots more time to see each patient is that you will bring in much less money now that med visits are paid by level of care and not time. Ex If you take 90 min to see an new patient and they bill 99204 vs same visit done in 30 min seeing 3 new patients in 90 minutes= triple the income/hour. They will either pay you less since you won't cover your own costs or they must have you scheduled to see more/ hour. if you have a high no show rate it's compounded.

 

[sunlioness]

I will look into the expanded hours. I think the backlog of patients is a temporary problem so that would help. I definitely need a nurse or care coordinator. I'm surprised that the other doctors have been able to carry on as long as they have without those support services in such a busy clinic. There are nurses but they are primarily giving injections and doing med management groups. They are not assigned to any of the providers. I do all my own refills, prior authorizations, paperwork, collateral contacts, returning calls from patients about questions, etc..All the patients have a therapist but they aren't responsible for those type of care coordination duties.

That's not okay. There are not words for how not okay that is.


Sent from my iPad using Tapatalk

 

[Shikima]

I will look into the expanded hours. I think the backlog of patients is a temporary problem so that would help. I definitely need a nurse or care coordinator. I'm surprised that the other doctors have been able to carry on as long as they have without those support services in such a busy clinic. There are nurses but they are primarily giving injections and doing med management groups. They are not assigned to any of the providers. I do all my own refills, prior authorizations, paperwork, collateral contacts, returning calls from patients about questions, etc..All the patients have a therapist but they aren't responsible for those type of care coordination duties.

Sounds like the VA.

 

[notdeadyet]

Sounds like the VA.

Except for the "I think the backlog of patients is a temporary problem" part...

 

[Shikima]

Except for the "I think the backlog of patients is a temporary problem" part...

No, I've heard that in the VA.

 

[psychdesoleil]

Perhaps that's wishful thinking on my part 🙂 I figured once I have worked through the transfers from the departed provider my intakes will be totally new the clinic, which I enjoy more anyways since its a chance to start fresh. There's no way they could schedule as many totally new intakes as the number of 45 minute transfer visits I'm doing now. That's partly my fault for insisting that I new new evals for all transferred patients but it was the only way I saw to provide safe care given what I had to work with. Its hard to see a transfered patient in 15 minutes and figure out what to do when they are not doing well, they have a paper chart 4 inches thick, their diagnostic eval from 1999 says "mood disorder" and they are on 2 atypical antipsychotics, Xanax and Adderall. Oh well, its my first job out of residency so I figure you live and learn. I do enjoy interacting with the patients here and its satisfying to see a lot of these people doing well despite their challenges. I'm trying to make the best of the situation and either see what can be changed or make notes on what to look for in the future.

 

[Doctor Bagel]

They really need to get you some help if you have to run PA's, make all return calls, etc. It's cheap to hire a RN or even a LPN to do this and the time it would free up for you could be filled with income producing visits. Many places like this don't want it that way, but are understaffed and can't easily fill the positions. Are they looking for more MD or ARNP's?

You don't need an RN or LPN for this. An MA could suffice for most of this. At the place I worked, the care coordinators generally had bachelor's degrees in something but weren't nurses.

 

[keifernny2]

You don't need an RN or LPN for this. An MA could suffice for most of this. At the place I worked, the care coordinators generally had bachelor's degrees in something but weren't nurses.

I agree, an RN is rarely necessary. The advantages of an LPN over an MA are that, in my state, LPNs have a license and MAs don't. This means that an LPN can triage within the bounds of their license and an MA can't. This can be a *huge* help, although other states may have different regulations on this.

 

[milesed]

Our state requires LPN or RN to call in rxs. Anyway, the point is to get some help for the non-clinical duties that you are performing.