VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

[IWillSurvive]

I've recently purchased this book to cope...

The Tyranny of Metrics

How the obsession with quantifying human performance threatens our schools, medical care, businesses, and government

press.princeton.edu

*Adds to Amazon cart*

---

Members don't see this ad.

 

[JustNoticing]

Anyone else being told they're under productivity expectations all of a sudden? I think they got a fancy new dashboard...oh joy

There's definitely renewed interest in this where I am. They're cutting back time for group prep, and time spent on training activities is looking like it could be on the chopping block as well. Even for those that are doing well on their RVUs

 

[cara susanna]

They've been obsessing over RVUs for over a year where I am. Or is this something different?

 

[IWillSurvive]

They've been obsessing over RVUs for over a year where I am. Or is this something different?

Interesting. It's new at my site. Typically, they haven't really cared too much but recently I'm told we are supposed to get around 2300 rvu's this year. Definitely didn't share that tidbit of info with us at the beginning of the fiscal year...

 

[IWillSurvive]

I am about to accept a tentative offer from another VA. The hiring manager hopes to have me start by March.

For those who have transferred to another VA without a break in service, do you have any pearls of wisdom for ensuring a smooth transition, such as when to inform my current supervisor & chief, HR specifics to be aware of, and anything else to keep in mind? Thanks!

I would appreciate info on this too. Do people wait until the formal offer to inform sups and patients? or the tentative?

 

[cara susanna]

I did tentative offer, but i didn't have time to wait. My new site wanted me to start asap

I would appreciate info on this too. Do people wait until the formal offer to inform sups and patients? or the tentative?

 

[beginner2011]

They've been obsessing over RVUs for over a year where I am. Or is this something different?

Yes, my memory is that it was early 2020 (pre-pandemic) that we had a big MHS staff meeting where Psychologists were essentially called to the carpet for low RVUs almost across the board. It was acknowledged this was a change of directive ("but we were told previously that it was the grid that was the metric to focus on!"), and leadership was rueful in relaying the change. There was talk that other professions were "next up" but then the pandemic hit and there hasn't been much talk of that. I'm also still a trainee, so may just be out of the loop.

 

[IWillSurvive]

Yes, my memory is that it was early 2020 (pre-pandemic) that we had a big MHS staff meeting where Psychologists were essentially called to the carpet for low RVUs almost across the board. It was acknowledged this was a change of directive ("but we were told previously that it was the grid that was the metric to focus on!"), and leadership was rueful in relaying the change. There was talk that other professions were "next up" but then the pandemic hit and there hasn't been much talk of that. I'm also still a trainee, so may just be out of the loop.

This is helpful to know because I felt I was singled out. I would have appreciated a formal meeting before being told in an individual meeting to contextualize things. Yes, this past year the obsession at my site has been on clinic utilization so I guess the pandemic delayed the rvu discussion at my site. Guessing this is how they will bring everyone back in off telework.

 

[AcronymAllergy]

This is helpful to know because I felt I was singled out. I would have appreciated a formal meeting before being told in an individual meeting to contextualize things. Yes, this past year the obsession at my site has been on clinic utilization so I guess the pandemic delayed the rvu discussion at my site. Guessing this is how they will bring everyone back in off telework.

In this case, because of how it seems like it was approached (i.e., the focus was changed without telling folks ahead of time), it could be. But if psychologists are seeing the same numbers of patients while teleworking that they would in the office, the wRVUs should be the same.

Also, if the grids are filled the way they're scheduled and clinic utilization is acceptable, wRVUs should fall in line. If they don't, it means either the clinics/grids weren't built correctly in the first place (generally not the psychologists' fault), or the psychologists aren't using encounter codes properly (which also could reflect an area that leadership should have addressed ahead of time via employee education).

As a very, very simplified example, assuming 48 working weeks a year of 4 days each week (trying to factor in vacation, no-shows and cancellations, etc.) and assuming a psychologist is only offering 90834 at 2.0 wRVUs, that's right under 6 patients/day. In terms of reimbursement, that (i.e., 6 patients/day, 4 days/week, 48 weeks/year) works out to right under $110k at 2020 Medicare rates. Assuming all my math is right. RVUs are the same for telehealth as for in-person visits.

 

[beginner2011]

In this case, because of how it seems like it was approached (i.e., the focus was changed without telling folks ahead of time), it could be. But if psychologists are seeing the same numbers of patients while teleworking that they would in the office, the wRVUs should be the same.

Also, if the grids are filled the way they're scheduled and clinic utilization is acceptable, wRVUs should fall in line. If they don't, it means either the clinics/grids weren't built correctly in the first place (generally not the psychologists' fault), or the psychologists aren't using encounter codes properly (which also could reflect an area that leadership should have addressed ahead of time via employee education).

As a very, very simplified example, assuming 48 working weeks a year of 4 days each week (trying to factor in vacation, no-shows and cancellations, etc.) and assuming a psychologist is only offering 90834 at 2.0 wRVUs, that's right under 6 patients/day. In terms of reimbursement, that (i.e., 6 patients/day, 4 days/week, 48 weeks/year) works out to right under $110k at 2020 Medicare rates. Assuming all my math is right. RVUs are the same for telehealth as for in-person visits.

Hmm...This might be the most generous estimate I've seen favoring VA employment. As a postdoc on the verge of making decisions about next steps I'm curious about this.

That math accounts for 3 full months of vacation days (4 day work weeks * 48 weeks = 48 vacation days + 20 days (due to 48 and not 52 week count) = 68 non-work days) with about 4.5 hours of F2F services per working day (.75 (90834 code) * 6 patients = 4.5). And this is assuming your caseload is 100% insurance patients.

That puts someone at 20h of total F2F services per week, on average.

Am I missing anything?

To my mind, taking a VA staff position is actually more like a public service than it is a sound financial decision. This may also be a reflection of the fact that I'm in a major metro where the locality adjustment is not appropriately weighted.

 

[JustNoticing]

Hmm...This might be the most generous estimate I've seen favoring VA employment. As a postdoc on the verge of making decisions about next steps I'm curious about this.

That math accounts for 3 full months of vacation days (4 day work weeks * 48 weeks = 48 vacation days + 20 days (due to 48 and not 52 week count) = 68 non-work days) with about 4.5 hours of F2F services per working day (.75 (90834 code) * 6 patients = 4.5). And this is assuming your caseload is 100% insurance patients.

That puts someone at 20h of total F2F services per week, on average.

Am I missing anything?

To my mind, taking a VA staff position is actually more like a public service than it is a sound financial decision. This may also be a reflection of the fact that I'm in a major metro where the locality adjustment is not appropriately weighted.

Even an expectation of 2300 RVUs is lower than the 2600 or so you might be expected to hit in other settings...this is a good thing. I think it's a pretty sound financial decision myself, but this might depend what the alternatives are in your area. Job stability/security, union gig, a pension, guaranteed raises plus COLAs from congress (there's already a proposed 3% raise bill for next year) etc. and I think you could do a whole lot worse. YMMV

 

[AcronymAllergy]

Hmm...This might be the most generous estimate I've seen favoring VA employment. As a postdoc on the verge of making decisions about next steps I'm curious about this.

That math accounts for 3 full months of vacation days (4 day work weeks * 48 weeks = 48 vacation days + 20 days (due to 48 and not 52 week count) = 68 non-work days) with about 4.5 hours of F2F services per working day (.75 (90834 code) * 6 patients = 4.5). And this is assuming your caseload is 100% insurance patients.

That puts someone at 20h of total F2F services per week, on average.

Am I missing anything?

To my mind, taking a VA staff position is actually more like a public service than it is a sound financial decision. This may also be a reflection of the fact that I'm in a major metro where the locality adjustment is not appropriately weighted.

I went with 4 days/week rather than 5 to take a very conservative approach of accounting for multiple no-shows, cancellations, scheduling errors, etc., per week, which are of course going to be sprinkled throughout rather than concentrated on a single day. If the expectation is a minimum of 30 hours of direct patient care/week, having 24 patients actually show up is an 80% show rate. And while 90834 is a 45-minute code, odds are many of your sessions may go a few minutes over that, and you'll also be using another few minutes for writing notes and preparing for your next session; I would assume closer to an hour's worth of actual work per patient. There are also going to be a few hours' worth of non-patient care duty expectations, such as meetings and training. And of course lunch.

 

[WisNeuro]

Even an expectation of 2300 RVUs is lower than the 2600 or so you might be expected to hit in other settings...this is a good thing. I think it's a pretty sound financial decision myself, but this might depend what the alternatives are in your area. Job stability/security, union gig, a pension, guaranteed raises plus COLAs from congress (there's already a proposed 3% raise bill for next year) etc. and I think you could do a whole lot worse. YMMV

The COLAs are not guaranteed. There have been several times where it's been frozen for multi-year periods, a couple of these periods being in recent years.

 

[Sanman]

Hmm...This might be the most generous estimate I've seen favoring VA employment. As a postdoc on the verge of making decisions about next steps I'm curious about this.

That math accounts for 3 full months of vacation days (4 day work weeks * 48 weeks = 48 vacation days + 20 days (due to 48 and not 52 week count) = 68 non-work days) with about 4.5 hours of F2F services per working day (.75 (90834 code) * 6 patients = 4.5). And this is assuming your caseload is 100% insurance patients.

That puts someone at 20h of total F2F services per week, on average.

Am I missing anything?

To my mind, taking a VA staff position is actually more like a public service than it is a sound financial decision. This may also be a reflection of the fact that I'm in a major metro where the locality adjustment is not appropriately weighted.

Well, yes you are missing a few things.

1. That 110k is not all vacation as AA mentioned, but no shows and cancellations that you have in any position. You would have equivalent free time at a VA position with 4 weeks vacation (granted it often means sitting in your office, but not always).

2. You have not accounted for federal benefits, which has been calculated to be about $36k. So., substract $36k from that $110k
Average Total Federal Employee Compensation: $123,160

3. What salary are you comparing it to? Full potential in most cases is gs13 step 10. Most of those people are making between $120-140k plus benefits mentioned above. Even a GS13 step 1 should start around 90k plus benefits.

4. Federal pay scale has a tendency to increase over the years (despite possible freezes) so a gs13 step 10 in a few decades will likely make $130-150k. Medicare rates have been relatively stagnant since the year 2000 and most APA salary surveys have really been flat as well at around the $90k mark.

That said, if working in you own business/PP there are other benefits. If taking an employed position in a private company, hospital ,etc. I don't think you will do much better as a full time clinician. The caveat comes in if you want to work more in order to make more. This is often more limited in the federal system than a private one. However, nothing stops you from taking a side gig.

 

[AcronymAllergy]

Some VA systems will also approve overtime (paid at your regular hourly salary) in some circumstances, such as if you're backlogged. You could likely make more by seeing patients/clients via a side gig, but VA overtime would save you the extra practice-associated costs and administrative components.

There are definitely pros and cons, as there are with any job. I would say relative to 100% clinical positions in other large healthcare/hospital systems, VA ain't bad. And VA's research and training positions, if you can find them, seem to keep folks pretty happy. It all just depends on what you're looking for in a job and what you value personally and professionally.

 

[beginner2011]

Some VA systems will also approve overtime (paid at your regular hourly salary) in some circumstances, such as if you're backlogged. You could likely make more by seeing patients/clients via a side gig, but VA overtime would save you the extra practice-associated costs and administrative components.

There are definitely pros and cons, as there are with any job. I would say relative to 100% clinical positions in other large healthcare/hospital systems, VA ain't bad. And VA's research and training positions, if you can find them, seem to keep folks pretty happy. It all just depends on what you're looking for in a job and what you value personally and professionally.

Yea, thanks for clarifying. I was just a bit thrown by the conservative estimates for hours, but I see you were accounting for no shows/cancelations/etc. because we were talking about RVUs as opposed to gridded hours. Makes total sense.

I think one of the things that I find frustrating about VA is that I think that I spend a lot of time at work but don't actually do as much psychotherapy or assessment during those hours (underutilized; 20h of F2F= 40h of work) as I could if I weren't part of a big health care system. One fantasy I have is that private practice would allow me to be more efficient with my time (20h of F2F = 30h of work), have a similar income, and have more time for family.

 

[cara susanna]

In this case, because of how it seems like it was approached (i.e., the focus was changed without telling folks ahead of time), it could be. But if psychologists are seeing the same numbers of patients while teleworking that they would in the office, the wRVUs should be the same.

Also, if the grids are filled the way they're scheduled and clinic utilization is acceptable, wRVUs should fall in line. If they don't, it means either the clinics/grids weren't built correctly in the first place (generally not the psychologists' fault), or the psychologists aren't using encounter codes properly (which also could reflect an area that leadership should have addressed ahead of time via employee education).

As a very, very simplified example, assuming 48 working weeks a year of 4 days each week (trying to factor in vacation, no-shows and cancellations, etc.) and assuming a psychologist is only offering 90834 at 2.0 wRVUs, that's right under 6 patients/day. In terms of reimbursement, that (i.e., 6 patients/day, 4 days/week, 48 weeks/year) works out to right under $110k at 2020 Medicare rates. Assuming all my math is right. RVUs are the same for telehealth as for in-person visits.

My RVUs are lower than the target because I get a lot of cxs and NSes, and not all of my sessions go the full 38 min. Although some of it was also me undercoding, so fingers crossed that this year is better!

 

[AcronymAllergy]

Yea, thanks for clarifying. I was just a bit thrown by the conservative estimates for hours, but I see you were accounting for no shows/cancelations/etc. because we were talking about RVUs as opposed to gridded hours. Makes total sense.

I think one of the things that I find frustrating about VA is that I think that I spend a lot of time at work but don't actually do as much psychotherapy or assessment during those hours (underutilized; 20h of F2F= 40h of work) as I could if I weren't part of a big health care system. One fantasy I have is that private practice would allow me to be more efficient with my time (20h of F2F = 30h of work), have a similar income, and have more time for family.

No problem. And yes, 20 hours/week of patient care would be below pretty much every guideline or expectation I've ever seen, unless the provider has time devoted to other areas. I'd expect actual grids to probably be something like 80+% allocated for clinical duties (i.e., 30-32+ hours/week). Like you've said, the biggest issues in terms of actual time spent in patient contact tend to be cancellations, no-shows, and other administrative snafus (e.g., patient's return to clinic order isn't processed, so the appointment doesn't end up "on the books" and neither the patient nor provider remember it).

I suspect time in private practice has the potential to be much more efficient, depending on the individual and in no small part because efficiency is more directly reinforced in PP (i.e., by making more money). You also get to control what meetings you sent, how you want to document, how administrative tasks are divvied up, etc.

 

[AcronymAllergy]

My RVUs are lower than the target because I get a lot of cxs and NSes, and not all of my sessions go the full 38 min. Although some of it was also me undercoding, so fingers crossed that this year is better!

Ideally, patient cancellations and no-shows would be taken into account to adjust productivity targets downward (same with other things, like sick and annual leave). Realistically, this probably doesn't happen.

 

[Sanman]

Yea, thanks for clarifying. I was just a bit thrown by the conservative estimates for hours, but I see you were accounting for no shows/cancelations/etc. because we were talking about RVUs as opposed to gridded hours. Makes total sense.

I think one of the things that I find frustrating about VA is that I think that I spend a lot of time at work but don't actually do as much psychotherapy or assessment during those hours (underutilized; 20h of F2F= 40h of work) as I could if I weren't part of a big health care system. One fantasy I have is that private practice would allow me to be more efficient with my time (20h of F2F = 30h of work), have a similar income, and have more time for family.

This is possible. However, it really depends on how you set up a private practice. You won't make enough to have a large staff, so you might not want to deal with insurance hassles if you work less time. Okay so small cash practice.

Then come the questions:

1. Do you own your office or rent? If you rent will you make enough in 20 hours to cover your fixed rental costs? If you own, are you counting time getting toilet paper, office supplies, coffee/keurig pods, fixing leaks or clogged toilets, etc for the office as "work" because it is. Are you getting a cleaning service to come in or doing this yourself?

2. What kind of clientele/niche are you catering to that will bring in a consistent 20 hours of clinical work in cash? Is it consistent? Is is the same kind of clinical issue so you can cut down on prep time? Are you marketing to them ( and are you counting that as work)?

3. If you are catering to rich clientele, Count on December being quiet and summer as well. People with cash to burn go on vacations. You may as well also unless you want to be sitting around for 1 or 2 clients per day. IF you live where it snows or there is "weather" you will also get lots of cancellations on snow/bad weather days. Are you working more other months to make up for the quiet times?

I could go on. The point being that it really depends on what you consider work and how much income will satisfy you. Going to a party, giving a talk, etc to drum up business is barely work and could be a perk for some people and misery inducing necessity for others. Same thing with making a Costco run for office supplies and TP.

 

[cara susanna]

Ideally, patient cancellations and no-shows would be taken into account to adjust productivity targets downward (same with other things, like sick and annual leave). Realistically, this probably doesn't happen.

Yes, exactly. I also read somewhere on this forum that RVUs are a measure of efficiency, not productivity, and using them for the latter purpose is inherently flawed.

I think it's annoying that I essentially get punished for having an efficient, focused session. If I did 60 min of supportive therapy my RVUs would be better, do they really want that though? Not to mention that due to our system, I have trouble discharging patients who aren't actually doing work.

 

[Sanman]

Yes, exactly. I also read somewhere on this forum that RVUs are a measure of efficiency, not productivity, and using them for the latter purpose is inherently flawed.

I think it's annoying that I essentially get punished for having an efficient, focused session. If I did 60 min of supportive therapy my RVUs would be better, do they really want that though? Not to mention that due to our system, I have trouble discharging patients who aren't actually doing work.

Yes, until the EBP fairy smacks you with a naughty stick. Then again, if you just paste an EBP template into your note, you have done an EBP. It doesn't really matter what happened in session. That said, if you are getting yelled at, learn to stretch your sessions to maximize coding. No point in a 35 min session if it can be a 38 min session, welcome to the world we live in (inside the VA and out).

 

[WisNeuro]

This is possible. However, it really depends on how you set up a private practice. You won't make enough to have a large staff, so you might not want to deal with insurance hassles if you work less time. Okay so small cash practice.

Then come the questions:

1. Do you own your office or rent? If you rent will you make enough in 20 hours to cover your fixed rental costs? If you own, are you counting time getting toilet paper, office supplies, coffee/keurig pods, fixing leaks or clogged toilets, etc for the office as "work" because it is. Are you getting a cleaning service to come in or doing this yourself?

2. What kind of clientele/niche are you catering to that will bring in a consistent 20 hours of clinical work in cash? Is it consistent? Is is the same kind of clinical issue so you can cut down on prep time? Are you marketing to them ( and are you counting that as work)?

3. If you are catering to rich clientele, Count on December being quiet and summer as well. People with cash to burn go on vacations. You may as well also unless you want to be sitting around for 1 or 2 clients per day. IF you live where it snows or there is "weather" you will also get lots of cancellations on snow/bad weather days. Are you working more other months to make up for the quiet times?

I could go on. The point being that it really depends on what you consider work and how much income will satisfy you. Going to a party, giving a talk, etc to drum up business is barely work and could be a perk for some people and misery inducing necessity for others. Same thing with making a Costco run for office supplies and TP.

What about #4, mix in some IME work and get 4-12X your hourly rate working somewhere else?

 

[Sanman]

What about #4, mix in some IME work and get 4-12X your hourly rate working somewhere else?

It really goes back to #2. IME and EAP work often solve the getting payment while avoiding insurance hassles issue, just like cash clients. However, not everyone can get their hands on any of these types of work and keeping referral sources happy is important part of PP work as well. I have seen what happens when a major referral source gets pissed at you firsthand and it ain't pretty.

 

[WisNeuro]

It really goes back to #2. IME and EAP work often solve the getting payment while avoiding insurance hassles issue, just like cash clients. However, not everyone can get their hands on any of these types of work and keeping referral sources happy is important part of PP work as well. I have seen what happens when a major referral source gets pissed at you firsthand and it ain't pretty.

Definitely easier for those of us in assessment in some ways. Pretty easy to do billing for a handful of assessments a week vs. couple dozen therapy appointments. But,overall, in my experience, the transition was much easier than I thought it would be, I think people are just more afraid of teh uncertainty more than anything.

 

[Sanman]

Definitely easier for those of us in assessment in some ways. Pretty easy to do billing for a handful of assessments a week vs. couple dozen therapy appointments. But,overall, in my experience, the transition was much easier than I thought it would be, I think people are just more afraid of teh uncertainty more than anything.

Do you still have a job or are you transitioned to full-time PP?

 

[WisNeuro]

Do you still have a job or are you transitioned to full-time PP?

Full-time PP, all severanced and PTOd out, so a pretty big chunk of change to offset a bunch of one time expenses and then some.

 

[Sanman]

Full-time PP, all severanced and PTOd out, so a pretty big chunk of change to offset a bunch of one time expenses and then some.

Congrats!

 

[IWillSurvive]

Yes, exactly. I also read somewhere on this forum that RVUs are a measure of efficiency, not productivity, and using them for the latter purpose is inherently flawed.

I think it's annoying that I essentially get punished for having an efficient, focused session. If I did 60 min of supportive therapy my RVUs would be better, do they really want that though? Not to mention that due to our system, I have trouble discharging patients who aren't actually doing work.

I 100% agree with this! I probably undercode as well as you mentioned earlier...and I'm less talkative and more efficient and focused in sessions, which means I have a lot of 2.0 rvu's instead of 3.0.

 

[JustNoticing]

The COLAs are not guaranteed. There have been several times where it's been frozen for multi-year periods, a couple of these periods being in recent years.

I was talking about the step increases,...COLAs are at the whims of the politicians

 

[WisNeuro]

I 100% agree with this! I probably undercode as well as you mentioned earlier...and I'm less talkative and more efficient and focused in sessions, which means I have a lot of 2.0 rvu's instead of 3.0.

Undercoding can definitely be a problem, but over coding will potentially get you into more trouble. Recently reviewing notes for a legal case where a SW billed interactive complexity modifier because the pt "was anxious" during the clinical interview.

 

[beginner2011]

Undercoding can definitely be a problem, but over coding will potentially get you into more trouble. Recently reviewing notes for a legal case where a SW billed interactive complexity modifier because the pt "was anxious" during the clinical interview.

That could be an allowable condition under the CMS guidelines, couldn't it? Depending on the intensity and the degree of impact on communication?

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34616_20/L34616_PSYCH014_BCG.pdf

Interactive complexity may be reported with psychiatric procedures when at least one of the following communication difficulties is present:

1. The need to manage maladaptive communication (related to, e.g., high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.

 

[WisNeuro]

That could be an allowable condition under the CMS guidelines, couldn't it? Depending on the intensity and the degree of impact on communication?

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34616_20/L34616_PSYCH014_BCG.pdf

Allowable, but if you don't want to get audited and charged to get that money back, you need to document why that anxiety added to the complexity/difficulty. there was literally nothing in the documentation that supported the billing besides "anxious." IF that was all that was needed for billing, this add-on would be used for about 95% of MH patient interactions.

 

[Sanman]

Undercoding can definitely be a problem, but over coding will potentially get you into more trouble. Recently reviewing notes for a legal case where a SW billed interactive complexity modifier because the pt "was anxious" during the clinical interview.

It seems to me that this is just a case of poor understanding of the coding system and proper documentation (something that I see all the time; mid-levels more than psychologists). I have started doing a didactic on this for trainees for just such a reason. It isn't like that code gets you much more in terms of money and RVUs. like it will in the E/M codes. I feel like most upcoding/under coding gets done on the time end and it often due to lazy timekeeping (that was about an hour, 90837...even if it was 50 min)

 

[cara susanna]

What actually is the consequence if you don't do the three phone calls for a NS?

 

[Sanman]

Absolutely nothing for me as I can't discharge any of them from the primary care team anyway and they will just be referred back to me. I really don't think it matters much unless you are discharging a patient and need to prove you made the effort if they come back and complain.

 

[Fan_of_Meehl]

What actually is the consequence if you don't do the three phone calls for a NS?

"Yo Ho, fiddle dee dee..."

Keelhauling - Wikipedia

en.wikipedia.org

 

[AbnormalPsych]

Absolutely nothing for me as I can't discharge any of them from the primary care team anyway and they will just be referred back to me. I really don't think it matters much unless you are discharging a patient and need to prove you made the effort if they come back and complain.

This is what I guessed, CYA material. I still do this to this day outside of VA because of this reason, CYA. Unless the person says the want to discontinue that is. Never heard of any actual consequences.

 

[Fan_of_Meehl]

This is what I guessed, CYA material. I still do this to this day outside of VA because of this reason, CYA. Unless the person says the want to discontinue that is. Never heard of any actual consequences.

Even though I disagree with the policy (I think clinician discretion should come into play here), I follow it to avoid the hassle from admin/auditors, but more importantly I wouldn't want to have a client commit suicide/homicide and have to deal with a, say, board complaint and have it pointed out that I failed to follow the institutional policy/procedure regarding followup after a no-show. They may conclude that I was negligent for failing to follow institutional policies and that, had I followed them, could have prevented the adverse outcome.

 

[Fan_of_Meehl]

Even though I disagree with the policy (I think clinician discretion should come into play here), I follow it to avoid the hassle from admin/auditors, but more importantly I wouldn't want to have a client commit suicide/homicide and have to deal with a, say, board complaint and have it pointed out that I failed to follow the institutional policy/procedure regarding followup after a no-show. They may conclude that I was negligent for failing to follow institutional policies and that, had I followed them, could have prevented the adverse outcome.

This being said, I have had scenarios where I made the first (or second) no-show followup call but then (without my involvement/awareness) they had called the front desk and rescheduled. In most of these cases, especially when the scheduled appointment is in a few days, I won't bother with the 2nd or 3rd call. The auditors may 'ding' me but it just seems ridiculous for me to hassle someone with a THIRD followup call (today) when they called in and successfully rescheduled with the clerk (yesterday) and I am going to be seeing them for a phone/VVC session (tomorrow morning) at 9am.

 

[cara susanna]

This being said, I have had scenarios where I made the first (or second) no-show followup call but then (without my involvement/awareness) they had called the front desk and rescheduled. In most of these cases, especially when the scheduled appointment is in a few days, I won't bother with the 2nd or 3rd call. The auditors may 'ding' me but it just seems ridiculous for me to hassle someone with a THIRD followup call (today) when they called in and successfully rescheduled with the clerk (yesterday) and I am going to be seeing them for a phone/VVC session (tomorrow morning) at 9am.

Oh yeah, if they do that I just put an addendum saying that they contacted the clinic and r/s, so I won't be making any additional contact attempts. I think that seems more than fair. At that point it could feel more like harassment IMO.

 

[Sanman]

Even though I disagree with the policy (I think clinician discretion should come into play here), I follow it to avoid the hassle from admin/auditors, but more importantly I wouldn't want to have a client commit suicide/homicide and have to deal with a, say, board complaint and have it pointed out that I failed to follow the institutional policy/procedure regarding followup after a no-show. They may conclude that I was negligent for failing to follow institutional policies and that, had I followed them, could have prevented the adverse outcome.

I think that this is a fair point depending on where you work. I would also add that it needs to be put in if cancelling a consult. Given that most of my folks are bedbound with a fulltime caregiver, I am less concerned about suicide due to access to means. That said, I doubt that you would get in much trouble for not making a third phone call if a suicidal person no showed and killed themselves. I have had a lot of no shows due to all the extra stress on caregivers and lots have forgotten phone calls. If I did that for everyone, I would be doing nothing else. My PTSD and chronic depression folks, I attend to more diligently.

 

[AbnormalPsych]

This being said, I have had scenarios where I made the first (or second) no-show followup call but then (without my involvement/awareness) they had called the front desk and rescheduled. In most of these cases, especially when the scheduled appointment is in a few days, I won't bother with the 2nd or 3rd call. The auditors may 'ding' me but it just seems ridiculous for me to hassle someone with a THIRD followup call (today) when they called in and successfully rescheduled with the clerk (yesterday) and I am going to be seeing them for a phone/VVC session (tomorrow morning) at 9am.

Hold up. VA still expects you to outreach if they have already rescheduled?

 

[Fan_of_Meehl]

Hold up. VA still expects you to outreach if they have already rescheduled?

This may be site specific and related to how the policy/procedures are worded. Ours clearly states that the provider must try x3 (regardless of circumstances) because it is a 'safety assessment' after the no-show which must, perforce, be conducted by the provider. It appears to be based on the rather absurd assumption that a routine no-show to an outpatient MH appointment represents some form of sentinel event indicating heightened risk. It's asinine but social workers and clerks run our facility...not doctoral-level providers.

 

[cara susanna]

This may be site specific and related to how the policy/procedures are worded. Ours clearly states that the provider must try x3 (regardless of circumstances) because it is a 'safety assessment' after the no-show which must, perforce, be conducted by the provider. It appears to be based on the rather absurd assumption that a routine no-show to an outpatient MH appointment represents some form of sentinel event indicating heightened risk. It's asinine but social workers and clerks run our facility...not doctoral-level providers.

I mean, if they call to r/s they're clearly alive...

 

[Sanman]

I mean, if they call to r/s they're clearly alive...

VA central office cannot be sure they are alive without a clinical reminder. They will be installing a one question clinical reminder to all staff to ask whether a veteran is alive when he or she calls the facility. There will be a three page follow-up screening if the veteran responds that they are not alive.

 

[WisNeuro]

VA central office cannot be sure they are alive without a clinical reminder. They will be installing a one question clinical reminder to all staff to ask whether a veteran is alive when he or she calls the facility. There will be a three page follow-up screening if the veteran responds that they are not alive.

Also, a Columbia will need to be performed in each and every interaction with a Vet. Quest for Zero!

 

[Sanman]

Also, a Columbia will need to be performed in each and every interaction with a Vet. Quest for Zero!

Sadly, that one is actually already true...well annually not at every interaction, yet

 

[beginner2011]

Also, a Columbia will need to be performed in each and every interaction with a Vet. Quest for Zero!

I'm curious. For folks in the PP world, do you document risk assessment in each clinical note for every interaction with every client? I feel like I've been in VA long enough now I don't even remember what's normal anymore. E.g., it seems excessive to document risk assessment for a 2min scheduling phone call with a low acute/chronic risk patient, but c'est la vie.

 

[Fan_of_Meehl]

Sadly, that one is actually already true...well annually not at every interaction, yet

My favorite is being told I have to process a clinical reminder to screen for depression in a patient whom I've already diagnosed with major depressive disorder and already given the PHQ-9 to today.