Per Diem Work in urgent care

[Phooey]

I plan on starting some per diem work in urgent care next month. I was hired through a staffing company to cover shifts as needed. I will get subsidized malpractice insurance for this work and I will be keeping my 8-5 job in occ med. Are there any financial, legal or regulatory issues I need to consider before starting the per diem work? Any pointers specific to urgent care?

Thanks.

[Phooey]

I plan on starting some per diem work in urgent care next month. I was hired through a staffing company to cover shifts as needed. I will get subsidized malpractice insurance for this work and I will be keeping my 8-5 job in occ med. Are there any financial, legal or regulatory issues I need to consider before starting the per diem work? Any pointers specific to urgent care?

Thanks.

[Febrifuge]

UC fundamentally suffers from two misconceptions, among those who observe it from outside as well as many of those who practice it. Remember two things, and you'll save yourself and others a lot of headaches...

 

1) it's not the ER.

Lego brick up the nose? Dislocated finger? Nasty sinus infection? Great. But "I didn't want to wait at the ER" or "but my primary care person is in this clinic" are not in themselves reasons to be in the UC as opposed to somewhere else. One good rule of thumb is to ask, "if I were seeing this person in the ER, what would I do?". If the answer is tests and exams you can do in UC, no problem. If your lab can do a CBC but not a BMP, or you have xray but not ultrasound, and you really would like to do a test you can't -- send 'em. It's nice that you can keep some folks away from the ER, but that's not your main purpose; the purpose is to treat stuff you can treat well, with what you have.

 

I send about one patient per two weeks, or one in 125 or so, to the ER.

 

2) it's not a walk-in primary care clinic.

I see a lot of folks whose primary is in our building, during the day. If they've had a checkup and a talk about their meds in the past six months or year, cool. If not, I see them for today's issue and then refer them back for routine check-in, which they should be doing and no amount of seeing me in UC can ever take its place. Sometimes the patient walks in at 3pm, and there's no room on the schedule, so they "just go to Urgent Care." That's kind of lame. We aren't meant as an extension of primary care, and we're a pretty inefficient substitute.

 

I also give only a two-day supply of chronic pain meds, *if* I can document that they've been renewed before in the past and there's no care plan. I won't oppose any documentation from the prescriber that limits amounts of opioids. I'll renew inhalers or HTN or DM meds, but one month only and I'm requesting that appointment with primary care.

 

I have colleagues that start IVs and run fluids for hours; that's stupid. We have no cardiac monitors; we have minimal staff (a PA or NP plus a CMA or LPN). My SP explains it thusly: "if this is a problem that can be solved today, here, then good. If not, our job is to get them where they will get the answer or the treatment they need." Keep it simple.

[Febrifuge]

UC fundamentally suffers from two misconceptions, among those who observe it from outside as well as many of those who practice it. Remember two things, and you'll save yourself and others a lot of headaches...

 

1) it's not the ER.

Lego brick up the nose? Dislocated finger? Nasty sinus infection? Great. But "I didn't want to wait at the ER" or "but my primary care person is in this clinic" are not in themselves reasons to be in the UC as opposed to somewhere else. One good rule of thumb is to ask, "if I were seeing this person in the ER, what would I do?". If the answer is tests and exams you can do in UC, no problem. If your lab can do a CBC but not a BMP, or you have xray but not ultrasound, and you really would like to do a test you can't -- send 'em. It's nice that you can keep some folks away from the ER, but that's not your main purpose; the purpose is to treat stuff you can treat well, with what you have.

 

I send about one patient per two weeks, or one in 125 or so, to the ER.

 

2) it's not a walk-in primary care clinic.

I see a lot of folks whose primary is in our building, during the day. If they've had a checkup and a talk about their meds in the past six months or year, cool. If not, I see them for today's issue and then refer them back for routine check-in, which they should be doing and no amount of seeing me in UC can ever take its place. Sometimes the patient walks in at 3pm, and there's no room on the schedule, so they "just go to Urgent Care." That's kind of lame. We aren't meant as an extension of primary care, and we're a pretty inefficient substitute.

 

I also give only a two-day supply of chronic pain meds, *if* I can document that they've been renewed before in the past and there's no care plan. I won't oppose any documentation from the prescriber that limits amounts of opioids. I'll renew inhalers or HTN or DM meds, but one month only and I'm requesting that appointment with primary care.

 

I have colleagues that start IVs and run fluids for hours; that's stupid. We have no cardiac monitors; we have minimal staff (a PA or NP plus a CMA or LPN). My SP explains it thusly: "if this is a problem that can be solved today, here, then good. If not, our job is to get them where they will get the answer or the treatment they need." Keep it simple.

[ventana]

treat and street

 

I don't agree with the thought of no primary care medicine - if they want to pay and it is with in the spectrum of care provided by the clinic go for it

 

malpractice - make sure you get occurance or the staffing company pays for tail

 

I did this through a concentra - was a rude introduction to me the first shift when I was supposed to leave at 5 and they were still rooming patients at 6:30pm - the next shift it was a rude awakening for the office as at 5pm I said I was leaving in 20 minutes and they had to turn away any more patients (I was contracted till 5pm and don't mind a little extra but not blatant abuse.... all the regular full time providers thanked me for standing up to the 20 something practice manager that just always pushed to hard.)

 

Be aware of what you committment is, do a great job but then leave it all at the office (but don't do such a great job as to show up the full timers!)

[ventana]

treat and street

 

I don't agree with the thought of no primary care medicine - if they want to pay and it is with in the spectrum of care provided by the clinic go for it

 

malpractice - make sure you get occurance or the staffing company pays for tail

 

I did this through a concentra - was a rude introduction to me the first shift when I was supposed to leave at 5 and they were still rooming patients at 6:30pm - the next shift it was a rude awakening for the office as at 5pm I said I was leaving in 20 minutes and they had to turn away any more patients (I was contracted till 5pm and don't mind a little extra but not blatant abuse.... all the regular full time providers thanked me for standing up to the 20 something practice manager that just always pushed to hard.)

 

Be aware of what you committment is, do a great job but then leave it all at the office (but don't do such a great job as to show up the full timers!)

[Febrifuge]

I added a little more in my original post, about primary care. My point is that the primary person is most effective when, and because, they become the 'medical home base,' and the person who watches out for stuff over the long term. Continuity is important, and the UC can become a little bit of an impediment to it, if we're too easy to use instead of, rather than in addition to, primary care.

 

"My COPD is worse this week, I'm seeing Dr. Jones in 2 weeks, and I want to make sure it's not bronchitis" is a good reason to be in the UC. "It's been getting worse for the past six months, and I finally decided to do something about it, but I can't get in for two weeks" is a lot weaker reason.

 

I hasten to add, I never turn people away for stuff like that, I just make it clear my mandate is to make sure there's no acute, urgent problem for now (or treat one that exists, if it's within my means to treat). I'm not going to adjust BP meds or doses over the long term, for example. That's the primary's raison d'etre. Plus, I chose not to do primary care, and my colleagues and boss agree, this is not primary care.

 

Put another way: a patient who never sees a primary provider, just goes to the Urgent Care once a year because it's convenient, is probably getting lousy primary care. For one thing, nobody's getting to know them very well, and for another, nobody's screening and monitoring; we're just treating whatever issue brings them in. Asking UC to carry the ball for primary care is unfair, whether it's the group or the patient who's doing the asking.

[Febrifuge]

I added a little more in my original post, about primary care. My point is that the primary person is most effective when, and because, they become the 'medical home base,' and the person who watches out for stuff over the long term. Continuity is important, and the UC can become a little bit of an impediment to it, if we're too easy to use instead of, rather than in addition to, primary care.

 

"My COPD is worse this week, I'm seeing Dr. Jones in 2 weeks, and I want to make sure it's not bronchitis" is a good reason to be in the UC. "It's been getting worse for the past six months, and I finally decided to do something about it, but I can't get in for two weeks" is a lot weaker reason.

 

I hasten to add, I never turn people away for stuff like that, I just make it clear my mandate is to make sure there's no acute, urgent problem for now (or treat one that exists, if it's within my means to treat). I'm not going to adjust BP meds or doses over the long term, for example. That's the primary's raison d'etre. Plus, I chose not to do primary care, and my colleagues and boss agree, this is not primary care.

 

Put another way: a patient who never sees a primary provider, just goes to the Urgent Care once a year because it's convenient, is probably getting lousy primary care. For one thing, nobody's getting to know them very well, and for another, nobody's screening and monitoring; we're just treating whatever issue brings them in. Asking UC to carry the ball for primary care is unfair, whether it's the group or the patient who's doing the asking.

[EMEDPA]

I work some shifts at a local urgent care.

we do lots of primary care for several reasons:

there is a major shortage of pcp's available in the area who accept medicaid.

the one clinic that is taking new medicaid pts in our area has a 3 mo wait for new pts and a 5 week wait for established pts

we are open 24/7. lots of folks work m-f 9-5 which also happens to be the hours most clinics are open.

I always refer folks to primary care but am willing to accept that some folks will never go so we become their de facto pcp. in that regard I will start bp or thyroid meds or refill mdi's, etc after several visits when it becomes apparent that they will not go anywhere else. I will not refill chronic narcotics without a really good reason. best reason I heard recently (which was also true). "my doctor died last week and they can't get me in to see anyone else for a week". ok, fair enough.

[EMEDPA]

I work some shifts at a local urgent care.

we do lots of primary care for several reasons:

there is a major shortage of pcp's available in the area who accept medicaid.

the one clinic that is taking new medicaid pts in our area has a 3 mo wait for new pts and a 5 week wait for established pts

we are open 24/7. lots of folks work m-f 9-5 which also happens to be the hours most clinics are open.

I always refer folks to primary care but am willing to accept that some folks will never go so we become their de facto pcp. in that regard I will start bp or thyroid meds or refill mdi's, etc after several visits when it becomes apparent that they will not go anywhere else. I will not refill chronic narcotics without a really good reason. best reason I heard recently (which was also true). "my doctor died last week and they can't get me in to see anyone else for a week". ok, fair enough.

[Contrarian]

^^^ Agree with everything written in the above post^^^

Would also add... LOTS of folks can afford to pay for 3-4 visits a yr at the UC rate... but CANNOT afford to pay a couple hundred EVERY month on the off chance that they MAY become ill. Hence... NO insurance and therefore NO PCP.

[Contrarian]

^^^ Agree with everything written in the above post^^^

Would also add... LOTS of folks can afford to pay for 3-4 visits a yr at the UC rate... but CANNOT afford to pay a couple hundred EVERY month on the off chance that they MAY become ill. Hence... NO insurance and therefore NO PCP.

[Acebecker]

Contrarian makes a good point. But I agree most with Febrifuge - that's how I operate our urgent care clinic, pretty much to a 'T.'. Our clinic is attached to the hospital, though, so I am more like the minor care for the ER, too. It works well, though. I do send more people to the ER than Febrifuge, though - probably 6 out of the 80 Pts I saw this week. Some days it feels like all of them go down... Some days none will.

 

Andrew

[Acebecker]

Contrarian makes a good point. But I agree most with Febrifuge - that's how I operate our urgent care clinic, pretty much to a 'T.'. Our clinic is attached to the hospital, though, so I am more like the minor care for the ER, too. It works well, though. I do send more people to the ER than Febrifuge, though - probably 6 out of the 80 Pts I saw this week. Some days it feels like all of them go down... Some days none will.

 

Andrew

[CAdamsPAC]

A good many patients confuse Urgent Care/Convenient Care with Primary Care. Intermittent , irregular episodic care of the chronically ill patient is a dangerous path to follow. Refilling medications for patients I've never or rarely seen, patients without proper follow up labs studies, coordination of specialist referrals continued longitudinal care ARE NOT the purview of an Urgent Care practice. I feel that should I do these things I'm am not providing appropriate care and may even be failing to meet the "standard of care" for treatment of chronic illness. That's my $.02 worth on the suject.

[CAdamsPAC]

A good many patients confuse Urgent Care/Convenient Care with Primary Care. Intermittent , irregular episodic care of the chronically ill patient is a dangerous path to follow. Refilling medications for patients I've never or rarely seen, patients without proper follow up labs studies, coordination of specialist referrals continued longitudinal care ARE NOT the purview of an Urgent Care practice. I feel that should I do these things I'm am not providing appropriate care and may even be failing to meet the "standard of care" for treatment of chronic illness. That's my $.02 worth on the suject.

[Febrifuge]

Well-said.

[Febrifuge]

Well-said.