Patients limits in urgent care

[Bohuntr]

I have found myself seeing more and more patients a day, like most providers.  Recently, two of us saw 90+ patients in a 12 hour shift.

 

To me, this was not optimal patient care.  We were rushed to say the least, labs that would typically order were not ordered, basically, it was treat and street.  I hated that day, and sadly, they are increasing.  Our bonus are based on this model, considering we are an urgent care, our out is "f/u with PCP if no improvement in 48 hours" or "pt sent to ER" or "pt provided strict ER precautions" when patients leave our offices.

 

Everyone is checked in, even those with crushing chest pain, even though there is an ER 2 blocks away.  We can't do anything for an acute MI but watch it happen and call EMS, we always get patients come in with past chest pain and "want to make sure I didn't have a heart attack" but didn't want to go to the ER due to cost; providers have NO SAY in who gets checked in, the receptionist has orders to admit everyone because we can do something, even if it's a referral, then we bill.

 

We didn't start out this way, nobody does.  Has anyone ever drawn the line and said that XXXX number is it !  I can do no more safely or I'm going to miss something and not lost their job?

 

We started out very slow 4 months ago, now we are staying 2-3 hours (unpaid) a night to chart and have been getting unsolicited calls from our switchboard at home to our cell phones for patient calls in the middle of the night.  I blew a gasket the last time this happened and got written up for unprofessional behavior for telling the patient to go to the ER without even listening to her.  If it's so bad she had to call, she can go see someone who can bill her.

 

What are any of you experiencing?  Have you gone from pleasant place to work to a total nightmare in a short period of time recently?  I am guessing the ACA is doing it for us, we now have to take patients at the clinic due us being affiliated with a hospital, at most private clinics we would not be taking ACA patients; I know very few who will.  

 

Any other ideas?  I hate to see other people have this creep up on them and feel that it "just happened" to me.  It happened before me or my partner realized it, now we don't know what to do about it.  There is nobody we can complain too, we don't have a practice manager (there is one on paper, but he is afraid of sick people so he never shows up at the 4 clinics he is supposed to manage.  We are down to one MA per two providers and two providers cover 7 days a week.  

 

Again, this snuck up on us.  Any solutions that don't involve leaving?  Maybe something we can impement with a stealth plan?

 

 

[Bohuntr]

This was my post about loving my job on 6-July this year....  It's amazing how the practice has changed once the hospital got involved and started sending the ER patients that were not high acuity to our clinic to be seen (they have no real fast track or f/u method to speak of, so they decided to use our clinic) for f/u or iniital visits depending on the time of day it is.  I feel like we are the ER's dumping ground and the patients we used to get no longer want to come to us due to the other type of patient that lingers in our lobby our outside our doors smoking.  I"ve even seen patients waiting to be seen going to the store and sitting outside drinking!

 

 

 

 

 

06 July 2014 - 01:09 PM

I was like you for the first two years after graduation, I just wanted to forget I ever went to PA school and go back to my previous career.  All I could think of was how miserable I was with the never-ending flow of chronic complainers, non-compliant patients who continually make poor lifestyle choices, drug seekers and illegals.

 

Then I found my present job a few months ago.  I work at a family practice clinic right across from one of the largest Universities in the country.  I do primarily urgent care, but the Medical Director has a private practice that includes a lot of professors and their families so I occasionally get enough of her patients when she’s overbooked to ensure I don’t just see healthy college students.

 

My patients are typically 17-25, healthy, and come in with allergies, ear aches, STD’s, UTI’s, URI’s, fractures, minor suturing, depression, minor anxiety, etc… typically what you would expect from college age students.  I get to do a few ingrown toenails, cysts or lipoma removals to keep the basic procedural skills in tune, and can turn down anyone coming in seeking narcotics if I want to, though I have the option of prescribing if I believe it’s an honest need.  We are also associated with a hospital about a mile away, so I always have that option when patients need more care than I can give.

 

We have an OBGYN that comes in once a week I can refer to (as far as I’m concerned, that portion of the body is a playground, not an office space), and our Medical Director also does pelvic examinations during the week if it’s needed sooner.  The Medical Director is big into the Boston Heart protocol (it bills under preventative care) so she takes most patients with chronic conditions as part of her group; she tosses the pediatrics my way since that is one of my passions.

 

When our Medical Director is out I occasionally get a few of her patients, so I can keep up my knowledge and treatment of chronic conditions up to date, but don’t get pummeled with patients out test-driving their Obamacare after 30 years of poor lifestyle choices.  99% of my patients speak English, but as a campus I do get the occasional International Student who speaks Spanish, French, German, Russian, Arabic, etc… but their English is almost always enough to get them proper care; I have only had to send one patient to a hospital for an interpretive issue.  It’s not like the public hospital system where my Spanish-speaking patients with new onset knee pain were illegals who slipped on a mossy rock sneaking across the Rio Grande the night before. 

 

I know where you are coming from, but shop around.  You picked two fields, Ortho Spine and Occupational Medicine, that nobody should go into without several years in medicine.  Those patients are designed to turn people bitter.  I had 15+ years as a military medic before PA school and though ER would be the field for me, but I couldn’t have been more wrong.  I had the same bitter experience there that you feel right now, and it was all due to the chronic, bitter, ungrateful drug seekers and malingerers; everything that ends up in the fast-track side of the ER because nobody else wants to deal with them.

 

One thing I get in spades is where I'm at is GRATITUDE!, 99% of the people I see appreciate the care and time you spend with them.  Most of my patients are genuinely happy you spent the time to listen to them; they aren’t patients who have a government chip on their shoulder thinking they are getting the short end of the stick because they are on some low-income insurance program. 

 

Ever since I graduated PA school I have always asked the same two questions when the visit was over:

1. Do you understand our plan?  (I will give you a depo-medrol shot and Flonase, you will steam, take OTC Claritin and increase fluids.)
2. Do you have any questions you feel are unanswered?

In the walk-in urgent care clinics and ER's I worked many times I was told that they felt I was trying to get rid of them because they brought in a list of complaints and I would only address two.  Sorry, the words over the door say Emergency or Urgent, I'm not here to cure your 60+ years of poor lifestyle choices.

 

I shake hands with my patients at the end of the visit, give them a card and am building up a nice little group of repeats.

 

We have identical likes and dislikes for medical care, and I’m sure we aren’t in the minority.  Sadly, Obamacare is going to make medicine worse for the providers not better; the ungrateful chronic patients will eventually outnumber the grateful people who make responsible lifestyle choices. 

 

Sit down, find out where the patients you want to see are likely to go (maybe Dermatology, Plastic Surgery, a family practice clinic in a resort town, etc…. get creative, make your own niche if you can’t specifically find it) and start looking.

[EMEDPA]

maybe it's time to find a new job. in the mean time try this:

don't see patients faster than you feel is safe. triage the patients in the rack yourself by acuity. yes, chest pain comes before runny nose x 30 min. this means some folks will get a therapeutic wait. so be it. don't work for free. if you are writing charts later bill for it or only document on the clock. 45 pts in 12 hrs on a regular basis, especially with an emr, is not sustainable. 24-30 is a lot more reasonable, especially if there are some procedures in the mix. talk to someone about increasing staffing, both of providers and support staff. if they don't meet this reasonable request start looking for a new job ASAP.

no one should be calling you at home for an urgent care set up. this needs to stop now.

PS our volumes are up 30% in the last year as well. I just pace myself and if minor cases LWBS I am ok with that. Just always be ready to drop everything and see the patient who actually is really sick right now. everything else stops for an actual emergency pt.

[gbrothers98]

Unfortunately this seems to be happening when the little places get taken over.

Looks like the goal was to take the pressure off the ED, send the patients to where they really should be.

That volume of patients is not fun to work through. Doubly so for a provider who does not want to do that type of medicine.

The name of the game is volume, plain and simple.

Can reap the advantages of volume by leveraging, meaning few providers, more patients.

 

We were just discussing this at my place.

We are at the beginning of a lot of change in healthcare.

Right now it is still focused on making a buck.

What the focus will be a decade or 2 from now will probably be different.

Personally I hope that it becomes more of a service rather than the money making opportunity it is widely viewed.

 

Until then I can think of only 2 coping mechanisms.

 

One, find another job and leave. There is a lot of opportunity available and there is nothing better than telling a place that is mistreating you to f7(k off.

 

Two, stay and go to this person that is supposed to manage you and lay out that you need more help, what is occurring is unsafe, dont take calls after hours unless you are on call contractually. If there are complaints against you, this is like dealing with a borderline patient and their vortex, it will suck you in and take control of your behavior. Break the pattern now or you will get further down this path and wont be able to turn it around. If this doesnt work, then go back to the first option.

 

Sorry to hear about your good gig gone bad.

G Brothers PA-C

[Guest Paula]

Agree with GBrothers.  One stinkin' patient complaint can sink you and even tho you are trying to keep the patient's best interest in mind, those complaints are the only thing managers respond too.    I know, been there, done that, looking for another job currently. 

[primadonna22274]

45 is way too much. I once did 90 by myself in a 14-hr day...that was NOT good care. And these were the days of handwritten paper charts. I was beyond frustrated and sick and fed up. No way could I do more than half that many with EMR--if that.

[Febrifuge]

Man, I feel so lucky.

First, I'm paid straight hourly. Busy, not busy, doesn't matter. I'm paid to be here, look pretty, and practice good medicine. As are all healthcare organizations in my state, my employers are a non-profit, technically. I'm even in a union, so maybe I'm the 1% in terms of decent work environments, I don't know.

 

Second, if a lot of people come in at once, and we have a wait, I feel bad, but I am also very clear with the front desk, my nurse, and the patients that those are the breaks. It's the nature of non-scheduled, walk-in clinics that you take what you get. Sometimes people feel they don't want to wait. Sometimes people leave without being seen. I'm sure the group would like to collect some revenue for those folks, but oh well. In the meantime I've been busy seeing patients and generating revenue.

 

My bosses expect me to be able to handle 2.5 to 3 patients per hour, on average. In 8 hours, that's between 20 and 24. It can be annoying, but it's not dangerous. If I have to motor through and see a bunch of people and I have a stack of charts, I bill for the time. I have never had a problem getting paid for my time, because documentation is a part of care.

 

When that big bolus of people shows up and checks in all at once, I try to make sure the expectations are set. If there are 6 people ahead of you waiting to be seen, you should expect to wait about 2 hours. Sometimes the waiting room self-corrects. Sometimes people wait. Sometimes people are unhappy about the wait, but more often than not, I explain and apologize and they're sweet as pie when I see them. 

 

If you simply can't wait, you should be at the ER. We do our best to maintain an awareness of who's here and for what, and we try to catch the few truly sick people, but honestly: If you need triage, that's a part of the ER experience, not the UC. We also don't retrieve people from their cars, or walk them out to the parking lot. Experience has taught our group about the difference between a hospital, a health campus, and a clinic.

 

Bohuntr, it doesn't sound like the issue is that you are unhappy working in Urgent Care. It sounds like you're unhappy working in a dangerously mismanaged urgent care that is apparently operating on some crazy ideas. I mean, heck, I'm feeling a bit burned out lately, and dislike my 21:00 end time getting pushed to 23:30 because of all the notes left to do, but the care is still good and I don't worry somebody is going to die because management isn't supporting me. You need to decide if you can push back, and you need to be updating your CV.

[EMEDPA]

agree with everything said by Feb above (as usual...:) )

[Gordon, PA-C]

Your urgent care center needs to get one of those electronic "check in at home" apps that tells them when to come in so they dont have to wait all day.  It will make for far less angry patients.  

 

Of course your UC is so overwhelmed with patients I'm sure the app would tell the patients not to come in until the next day.  

[Boatswain2PA]

Febrifuge: "I'm paid to...., look pretty,...."

 

Yeah, I wouldn't get paid much for that! Lol.

 

Bohuntr- tough situation. Agree with all advice here, let us know how it works out.

[Acebecker]

I average 26-27 year round in a 10.5 hr day.  3 months of 20-22/day, then 9 months of 30+/day.  30 is comfortable in 10.5 hours.  My busiest day was 42 in 10.5 hours.  That was too much.  I hate more than 36 and when I'm trying to see 36 in 10 hours and there are complex patients - DVTs, r/o PE, diverticulitis, appendicitis, etc - I am destroyed by the end of the day. 

 

What gets me is trying to stay hypervigilant for 35 sore throat/runny nose/earache/acid reflux/uncomplicated UTIs/ankle sprains/water retention and not miss the one atypical ACS presentation or cerebellar stroke (presenting with vertigo), etc.  Burns me out.   

[SocialMedicine]

Not sure how useful this comment is ....

 

I read a few articles about the rise of urgent care recently. Many of the large groups borrowed/took investments in large sums. Think about the investment in bottom floor prime storefront property and all the equipment. I wonder if calculations are just not adding up even with high volume in todays medicine/reimbursement world. 

[SocialMedicine]

In NY there was a meningitis outbreak and the urgent care centers took out ads all over local bus stops and subway stops saying "Walk in for the vaccination be seen right away". They did not mention they billed for an office visit and vaccination if not covered. It was a good way to introduce themselves. Smart business minds involved that private practice folks can learn from.