What is a good number of patient's to see a day for outpatient psychiatry?

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18 adult patients and 14 child patients

What kind of time blocks are those? How many initial psychiatric evaluations?
 
I dont see how you can do any initial evals if seeing 32 pts a day. 32 pts a day would be 4x 15min visits for 8hours/day. sounds terrible. Also it is not the standard of care to do 15 min visits in child psychiatry except possibly very stable pts (e.g. ADHD). I calculate that on a production model you should be making over 900k/yr to accept such a job and get paid what you are worth.
 
I think one hour intake slots and 30 minutes for follow-ups is not unusual. The further you go under these limits the more stressful I think things would become. I would also want some daily administrative time (maybe 1 hour) built in.

As others have pointed out you are looking at 8 hours of 15-minute appointments with no admin time. That sounds horrible. The pay had better be amazing (or the no-show rate very high) if you are considering something like that.
 
30 minutes for follow-ups and 1 hour for intakes. That really should be the base standard you hold yourself to. That means no more than 16 patients in a day and generally considerably less. Think about what you would expect from seeing a doctor yourself. I'm definitely not a child expert, but I remember from residency it felt like two complete separate interviews with the kid and with the parent. I'm not even sure how people do that in 30 minutes, but I'm sure people do.
 
What I honestly don’t understand and I don’t mean disrespect is how you can complete a residency and not understand that that is just absurd..like are there residencies where people are taught that is standard? So strange
 
Techmed07 said:
I meant 14 kiddos a day max and on separate day see 18 adults max

lmao.. oh my god.
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That is more reasonable but 18 patients per day should be paying you 350k+ if it’s a regular thing
 
Techmed07 said:
Its a fqhc they are talking 285K.. They have a high no show rate
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285K is gonna be pretty solid for all outpatient FQHC in my opinion, especially if you're not being paid on productivity. Not for 18 patients a day consistently showing up though, those are probably gonna be long days if you're putting any effort into it at all.
 
Agree with 1 hour - new patient/half hour – review appointment structure.

My maximum capacity is for 17 patients (8.5 hour day with half hour lunch), and the most I’ve seen in one day being 21 - this included an emergency slotted in during my lunch space and an additional 3 inpatients after my regular hours. Was completely stuffed by the end of it with the only saving grace was that I didn't have excessive paperwork having new patients. A few months later caught up with an old medschool friend who is a child psychiatrist – he only saw 6 patients a day so thought what I was doing was nuts!

Glad OP clarified they’re not doing a pill mill set up. I think seeing 32 patients/day in 15 minute slots is physically possible, but would be extremely hard and mentally draining. There’s little leeway with late patients and you really have to limit consults to a single or simple issues which I suspect is not going to be satisfying for either yourself or your patient.
 
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Techmed07 said:
I meant 14 kiddos a day max and on separate day see 18 adults max

lmao.. oh my god.
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That would have been helpful to clarify, lol.

18 adults per day at a CMHC/FQHC is reasonable. I'd typically have 10-13 (13 was max) patients scheduled in a day with 2 hour-long intakes included. Mosts of the time would end up seeing 7-9 patients a day, but seeing 6 or less wasn't uncommon. 14 Kids a day seems a bit high, but with a high no-show rate is also probably reasonable. 285K guaranteed a year isn't bad for that many patients with high no-show rate.
 
Little high for my liking, would've taken max 15 adult 12 kids, maybe higher if they can prove the high no show rate. Salary is fine. Often what happens if you put in effort and the patient's like you, the no show rates aren't as high.
 
MedMan80 said:
Little high for my liking, would've taken max 15 adult 12 kids, maybe higher if they can prove the high no show rate. Salary is fine. Often what happens if you put in effort and the patient's like you, the no show rates aren't as high.
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Yeah on some level you can quickly make a crazy high volume job more tolerable by just being a bit s**t at it. Okay, maybe more than a bit realistically, but hey, potentially self-solving problem!
 
"They have a high no show rate" - I dont think this can last long due to wonders of AI/ message reminders/double bookings! I would be mentally prepared for a 99% show rate in the near future.
 
I think a max of 14-16 adults a day is fairly reasonable. Past that number then hopefully theyre all mild-mod complexity, and you have a good EMR
 
splik said:
I dont see how you can do any initial evals if seeing 32 pts a day. 32 pts a day would be 4x 15min visits for 8hours/day. sounds terrible. Also it is not the standard of care to do 15 min visits in child psychiatry except possibly very stable pts (e.g. ADHD). I calculate that on a production model you should be making over 900k/yr to accept such a job and get paid what you are worth.
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Where are you getting 900k number from?
 
You’re already running 10 minutes behind. Patient arrives 6 minutes late for a 20 minute follow up, schizophrenia, they decided they don’t need zyprexa anymore because they never had mental illness. Also getting more psychotic, thinking their neighbor is watching them through hidden cameras in their apartment. Patient makes a comment they might “ have to get him, before he gets me”.

You’re 18 patient day is now screwed.
 
nexus73 said:
You’re already running 10 minutes behind. Patient arrives 6 minutes late for a 20 minute follow up, schizophrenia, they decided they don’t need zyprexa anymore because they never had mental illness. Also getting more psychotic, thinking their neighbor is watching them through hidden cameras in their apartment. Patient makes a comment they might “ have to get him, before he gets me”.

You’re 18 patient day is now screwed.
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And this right here is why I've never considered outpatient work.
 
splik said:
On a wRVU basis, the median wRVU some years ago was $67.
a 15 min follow up is most likely a 99214 (1.92wRVUs)
46 weeks per year

1.92x 32 x5 x 46 = 946,790
This does not take into account no shows or other potential CPT codes.
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That sounds good but would any hospital actually pay this? I feel like they would cap you long before you reached anywhere close to that figure
 
forchinet121 said:
That sounds good but would any hospital actually pay this? I feel like they would cap you long before you reached anywhere close to that figure
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This would be another plug for going off on your own rather than through some corporate entity.
 
psych_0 said:
And this right here is why I've never considered outpatient work.
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It’s not that different from inpatient except instead of letting staff know they need to take care of this individual who is escalating, you just let local law enforcement know they need to handle it. Much rarer scenario in outpatient obviously. If they are that sick, they often don’t show at all because they are already headed to the hospital. Had one the other day where parent called and I tried to divert to hospital, but they showed up anyway. Five minutes later, they had left the office and were on the way to the hospital. What is funny is they never actually went to the hospital as they thought a hot springs would be more therapeutic and went there instead. Strong genetic link in this family.
 
smalltownpsych said:
It’s not that different from inpatient except instead of letting staff know they need to take care of this individual who is escalating, you just let local law enforcement know they need to handle it. Much rarer scenario in outpatient obviously. If they are that sick, they often don’t show at all because they are already headed to the hospital. Had one the other day where parent called and I tried to divert to hospital, but they showed up anyway. Five minutes later, they had left the office and were on the way to the hospital. What is funny is they never actually went to the hospital as they thought a hot springs would be more therapeutic and went there instead. Strong genetic link in this family.
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Idk, I'd be sketched out by letting an actively suicidal or schizophrenic with paranoid thoughts of killing strangers out of my office and off to the hot springs. I think I'll stay in my inpatient comfort zone.
 
smalltownpsych said:
It’s not that different from inpatient except instead of letting staff know they need to take care of this individual who is escalating, you just let local law enforcement know they need to handle it. Much rarer scenario in outpatient obviously. If they are that sick, they often don’t show at all because they are already headed to the hospital. Had one the other day where parent called and I tried to divert to hospital, but they showed up anyway. Five minutes later, they had left the office and were on the way to the hospital. What is funny is they never actually went to the hospital as they thought a hot springs would be more therapeutic and went there instead. Strong genetic link in this family.
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Whoa, say what? Where are you located that this is acceptable practice??

In my world when someone shows up for their outpatient appointment in holdable condition, you can't "let local law enforcement handle it." They're in your office already so they're your problem, you can't turf it to the local PD. You call the ED and the psych inpatient unit, inform them about the patient, place the hold, wait for security to show up, and accompany them to the ED to provide collateral and make sure admission goes smoothly. The whole thing takes 1-3 hours and completely destroys whatever else you had in mind for your day.

Luckily I usually have a resident or two around so I am often able to divide and conquer. I have no idea what people do in this situation when flying solo with a full slate of outpatient appointments scheduled.
 
psych_0 said:
Idk, I'd be sketched out by letting an actively suicidal or schizophrenic with paranoid thoughts of killing strangers out of my office and off to the hot springs. I think I'll stay in my inpatient comfort zone.
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Texas has some baseline paranoia about defending property. Have an uncle-in-law with 100+ guns, cameras all over his property, suppressors, and thermal scopes. He is sure someone is going to steal his stuff again and someone is probably casing his place periodically. No doubt he would shoot strangers that enter his property. He runs his own successful business that involves customer service. I call before visiting, but otherwise this is common “normal variant” in parts of Texas.
 
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Reactions: tr
tr said:
Whoa, say what? Where are you located that this is acceptable practice??

In my world when someone shows up for their outpatient appointment in holdable condition, you can't "let local law enforcement handle it." They're in your office already so they're your problem, you can't turf it to the local PD. You call the ED and the psych inpatient unit, inform them about the patient, place the hold, wait for security to show up, and accompany them to the ED to provide collateral and make sure admission goes smoothly. The whole thing takes 1-3 hours and completely destroys whatever else you had in mind for your day.

Luckily I usually have a resident or two around so I am often able to divide and conquer. I have no idea what people do in this situation when flying solo with a full slate of outpatient appointments scheduled.
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This just depends on the state; in one state I practice the police will show up and take the patient for inpatient care; in another state nothing will be done until ordered by a judge. Recently had a patient I wanted to IVC but PD declined as patient was in a different jurisdiction from our office (tele appointment) and they can only pick up IVC paperwork in person. In no scenario can I imagine holding a patient in the office against their will
 
tr said:
Whoa, say what? Where are you located that this is acceptable practice??

In my world when someone shows up for their outpatient appointment in holdable condition, you can't "let local law enforcement handle it." They're in your office already so they're your problem, you can't turf it to the local PD. You call the ED and the psych inpatient unit, inform them about the patient, place the hold, wait for security to show up, and accompany them to the ED to provide collateral and make sure admission goes smoothly. The whole thing takes 1-3 hours and completely destroys whatever else you had in mind for your day.

Luckily I usually have a resident or two around so I am often able to divide and conquer. I have no idea what people do in this situation when flying solo with a full slate of outpatient appointments scheduled.
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You can’t hold anyone against their wish, if someone shows up and they tell you they’re gonna kill themselves, you inform them you’d like to put them in the unit, if they leave then you call 911, you’re not gonna physically restrain the patient in your office
 
tr said:
accompany them to the ED
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I have never heard of going to the ED with a patient. Calling an ambulance and/or law enforcement to get the patient there is standard as is calling the ED in advance to provide your collateral and recommendation. But why would you need to physically show up with them? What more can you do beyond that?
 
tr said:
Whoa, say what? Where are you located that this is acceptable practice??

In my world when someone shows up for their outpatient appointment in holdable condition, you can't "let local law enforcement handle it." They're in your office already so they're your problem, you can't turf it to the local PD. You call the ED and the psych inpatient unit, inform them about the patient, place the hold, wait for security to show up, and accompany them to the ED to provide collateral and make sure admission goes smoothly. The whole thing takes 1-3 hours and completely destroys whatever else you had in mind for your day.

Luckily I usually have a resident or two around so I am often able to divide and conquer. I have no idea what people do in this situation when flying solo with a full slate of outpatient appointments scheduled.
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I don't understand this. You have a patient in your office that needs to be committed but wants to leave. How exactly are you physically keeping them in the office? And you have to go to the Ed to make sure the inpatient and ED doc do their jobs and admit the patient smoothly? This seems entirely excessive.
 
allantois said:
It is quite literally the job of the PD (or another designated agency) to transport IVC patients for inpatient treatment
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In a red state out west, I’ve had cops refuse to take people because “saying you’re suicidal” or a psychotic patient “threatening someone” is “freedom of speech”. Cops have no consequences for making bad decisions like this.
 
nexus73 said:
In a red state out west, I’ve had cops refuse to take people because “saying you’re suicidal” or a psychotic patient “threatening someone” is “freedom of speech”. Cops have no consequences for making bad decisions like this.
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Yep. At least the liability then shifts to them or the judicial system (aka no liability). Always puzzled me how judges cannot be sued for releasing suicidal patients who then kill themselves (lawyers wrote malpractice laws). As I said I just had a patient and the police refused to IVC because she “wasn’t suicidal”. Never mind she was grossly manic and disorganized and family took away her car keys and basically locked her in the house for fear of safety
 
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allantois said:
Always puzzled me how judges cannot be sued for releasing suicidal patients who then kill themselves (lawyers wrote malpractice laws).
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Judges cannot be sued period. They have judicial immunity. It is one of the bedrocks of the judicial system and one of the foundations of a supposedly independent judiciary. The notion is to prevent fear of lawsuits impeding the impartiality of any judicial determination. This extends even when decisions are made with corrupt or malicious intent. But judicial findings are subject to review from higher courts. In addition, state judges are elected and subject to recall or being voted out. Only SCOTUS judges are answerable to no one (though can be removed through impeachment like other federal judges).
 
psych_0 said:
Idk, I'd be sketched out by letting an actively suicidal or schizophrenic with paranoid thoughts of killing strangers out of my office and off to the hot springs. I think I'll stay in my inpatient comfort zone.
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This particular patient was more of a danger to one specific part of himself as he was reporting a medication side effect that was clearly beyond my scope to treat and from my understanding requires medical intervention.

If someone actually has a plan to kill others, I thought we had an obligation to report it to law enforcement. I sure as heck would not want to defend in a lawsuit why I didn’t report someone getting who said they contemplating this. I wouldn’t try to keep them in my office, I would just let the police know what’s going on and they do what they will with it. As others have stated, guess it depends on the local community how they will handle it. Most of the places I have practiced, law enforcement has been fairly helpful and we had a good collaborative relationship. There is some ways natural tension between the two disciplines as we interact with our different roles and perspectives, but I find that if we ask for help as opposed to try to tell them what to do, they are usually eager to provide that assistance. Once we call them, they take over and that is important to know.

Regardless, this type of situation is pretty rare in an outpatient setting especially when compared to inpatent. I actually think my own inpatient experience helped me to build the skills necessary to work with some of the more severe patients in an outpatient setting and be pretty calm when dealing with crises compared to the average outpatient therapist who doesn’t have that experience. It’s also why when I have sent patients to the hospital, they are typically admitted since I have already evaluated the other means and plans to not admit them since that was something I used to do at the hospital. I used to d/c patients from the ED from community therapists all the time. Stuff like 15 year old with cuts that don’t need stitches with no intent or thoughts to kill self or someone with passive SI and their response to what Is their plan is, “I could never do that, I was just worried because I was having these thoughts that life might not be worth living so I told my therapist and they sent me here.” An outpatient like that is what I see every day. When the spouse of an intoxicated ex-cop calls me and says he is threatenting to blow his brains out, and I send him to the hospital, he gets admitted.
 
nexus73 said:
In a red state out west, I’ve had cops refuse to take people because “saying you’re suicidal” or a psychotic patient “threatening someone” is “freedom of speech”. Cops have no consequences for making bad decisions like this.
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This is what 'defund the police' gets.

Local LEO in my area are doing this, too. Except they don't bother to say freedom speech, just we won't come unless there is an active weapon in hand. State passes numerous anti police laws, and now they have slower recruitment, faster attrition, and less personal motivation to do their jobs. I don't blame them. You shoot a criminal and if happens to be person of XYZ race main stream media torches you for being racist. The LEO are now open for civil lawsuits. [Think about the stress we carry of people suing us, just for doing our jobs!] Crime is skyrocketing in this area. One city PD is dropping their drug units - likely because DA aren't prosecuting, so why wasted time catching them? Detectives are being diverted to road patrol duties. Less resources to work up murders or child abuse etc. Good for the cops for pulling back. Society scats on them, why should they stick their neck out for society? Liberal policies are getting what have sewn. One of the heavier reasons why I am leaving for a red state. In the time span of my private practice I have witnessed homeless camps pop up outside my office, people bathing outside my office, people tying into the electric grid of this office, a neighboring gas station get broke into and now has metal bars. The list goes on. I support the police and I support their saying 'nope' we won't address the mental health calls. Good for them. Maybe the liberal state should follow through with the proclamations of social workers embedded with the police and responding to the calls. Can't wait to see that version of 'Cops.'

The funny thing is, American's don't realize how good our LEO are. Travel to a few other countries, and when you have to start carrying extra money on your person, just for the cop bribes, you quickly realize, 'Thank God I'm an American' but at this pace, these policies will quickly erode that. Not servicing the mental health calls is one of the early symptoms.

I suggest, the APA and others change their tunes, and become pro police. Pro LEO will ultimately mean better healthcare for mental health disorders. This should be a core policy push in the med societies.
 
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Sushirolls said:
This is what 'defund the police' gets.

Local LEO in my area are doing this, too. Except they don't bother to say freedom speech, just we won't come unless there is an active weapon in hand. State passes numerous anti police laws, and now they have slower recruitment, faster attrition, and less personal motivation to do their jobs. I don't blame them. You shoot a criminal and if happens to be person of XYZ race main stream media torches you for being racist. The LEO are now open for civil lawsuits. [Think about the stress we carry of people suing us, just for doing our jobs!] Crime is skyrocketing in this area. One city PD is dropping their drug units - likely because DA aren't prosecuting, so why wasted time catching them? Detectives are being diverted to road patrol duties. Less resources to work up murders or child abuse etc. Good for the cops for pulling back. Society scats on them, why should they stick their neck out for society? Liberal policies are getting what have sewn. One of the heavier reasons why I am leaving for a red state. In the time span of my private practice I have witnessed homeless camps pop up outside my office, people bathing outside my office, people tying into the electric grid of this office, a neighboring gas station get broke into and now has metal bars. The list goes on. I support the police and I support their saying 'nope' we won't address the mental health calls. Good for them. Maybe the liberal state should follow through with the proclamations of social workers embedded with the police and responding to the calls. Can't wait to see that version of 'Cops.'

The funny thing is, American's don't realize how good our LEO are. Travel to a few other countries, and when you have to start carrying extra money on your person, just for the cop bribes, you quickly realize, 'Thank God I'm an American' but at this pace, these policies will quickly erode that. Not servicing the mental health calls is one of the early symptoms.

I suggest, the APA and others change their tunes, and become pro police. Pro LEO will ultimately mean better healthcare for mental health disorders. This should be a core policy push in the med societies.
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Red states are not defunding police. Hopefully no one is shooting suicidal patients in crises
 
Is the psychiatry forum becoming Sushi’s personal “spout republican talking points” forum? I feel like I’m watching a new era unfold here over the past few months.

I guess you missed the RED STATE part you quoted from @nexus73. Police funding isn’t going down in any way shape or form in most of the country, that’s pretty clear, and the “defund the police” thing never actually played out in any large scale.

This false comparison game is always fun too. How about travel to Canada or the UK or Germany, actual comparable developed countries, and compare your interactions with police there to here? Comparing interactions with India or Mexico isn’t really an honest comparison, but I suspect you know that.
 
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