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Thanks for your feedback about sharing the Fairway Mortgage Nurse Practitioner loan program. Here is some more information about how they document income for 1099 independent contracts, which will apply to most traveling nurse practitioners.

As you might know, with conventional loans this can be a real challenge because if you don’t have a full two-year history, they consider you self-employed, and there’s virtually no way to get the loan done. The great thing about Fairway’s loan programs is they will allow a client to qualify based on 1099 income sometimes without any history at all. It depends on the employment contract, and how it’s worded, and if there’s some guarantees in there.

Often times they can do just an employment or offer letter for a 1099 or independent contractor. You don’t even need your first paycheck stub. Now if you’re already on the job, no problem. They have solutions for that as well. If you’re an independent contractor, you’ve run into some challenges getting financing, or you anticipate you might run into challenges, I welcome you to contact them through their website at: https://nursepractitionerhomeloans.com/ for more info.

As many of you know, I despise when the term ‘mid-level’ is used to describe us nurse practitioners. When I correct people that use that term, sometimes they ask what title I would prefer to be called. I tell them to just call me what I am, a nurse practitioner. I don’t know why there is even a word at all to group nurse practitioners and physician assistants together. Does it really save that much time instead of saying both titles? Not to mention that nurse practitioners and physician assistants are very different, with a different model of care.

I like the word ‘provider’ since we can interchangeably use it in PCP. PCP originally stood for primary care physician, but these days a lot of places use it to mean primary care provider. Another term that I have heard been used before is ‘clinician’. Although this title is not often used, I like it a lot. It represents what we really are, clinical experts. However, my issue is that is doesn’t encompass the fact that nursing is both a science and an art.

I don’t know why we even have to be grouped with physicians or physician assistants in the first place. As nurse practitioners become more popular, I prefer when organizations or patients just specify who they see. I like when patients say “I saw the nurse practitioner in the ER” or when clinic managers say “we are proud of what our physicians, nurse practitioners, and physician assistants have been doing.”

What are your thoughts? Is there a preferable way you like to be called?

With that being said, I really liked this article called “Don’t Call Me a Mid-Level Provider!”

After Maine, I ended up covering a clinic in Ft. Lauderdale, FL for one week. The physician is a family friend and he asked me to let him know when I was available to provide coverage for one week, so that he could go on vacation. This way he wouldn’t have to close down his clinic, and there would be a provider present to see patients and provide medication refills etc.

Since we wouldn’t be going through an agency (lucky him), I charged him a higher hourly rate than I usually am paid through the agency. At first, he was looking to pay a lower rate than I was charging. He only wanted to pay $60/hour which is what permanent nurse practitioners make in the area.

However, I told him through an agency he would normally have to pay double that, since they are filling a demand and it is pretty costly. I was only charging him $90/h since we weren’t going through an agency, but realistically there is a premium for locum nurse practitioners. This is because I can easily learn the EHR (electronic health record) they are using in a matter of minutes and wouldn’t need a thorough orientation to provide coverage for one week. A non-locums provider, wouldn’t be able to jump into a new environment and start seeing patients within the first hour, as I am.

Eventually he agreed to my rate and I made sure to draft up a contract which stated the requested dates and hours to be worked, and the hourly pay. I also made sure that he added me onto his malpractice coverage. Since I wasn’t going through an agency, I had to be sure I was protecting myself – family friend or not.

Covering his clinic was pretty straight forward. His practice used Practice Fusion EHR which I was familiar with. The patient load was fair, about 12-15 patients per day. The majority of the patient population were Haitian, so it was fun practicing my Haitian Creole and French.

I realized how different the Haitian population is in comparison to their neighboring Hispanics. Hispanic patients typically come with a list of complaints and want to take as many medications as possible. Haitian patients seemed to be more shy and won’t tell you if something is bothering them unless you ask them directly. They aren’t interested in taking medications or even accepting that they are “sick”. This can be a bad thing because it seemed that a lot of them had complex chronic illnesses that could have been treated better early on, had the patient been compliant or honest.

I had forgotten how South Florida clinics sometimes run on Caribbean time. Meaning, patients often showed up 30-45 minutes late to their appointment but were still expected to be seen (by both staff and patient). In addition, they didn’t mind waiting an hour to be seen by the provider. Obviously, in more Americanized clinics, patients are considered no shows if they are more than 10 minutes late. And it’s all about lowering “wait times”.

I had a good experience covering the clinic for one week. I was a bit nervous at first since it was the first time I was doing this without the help or guidance of an agency. But everything worked out well. I suppose my 4 years of being a traveling nurse practitioner paid off.

My only issue was after completing the assignment, the physician of the clinic provided me with some unnecessary feedback. It was mostly just nit picking of my documentation. He told me I should describe how my patients look better (such as tall, obese, Caucasian, black). He said if a patient is anemic I should specify mild or severe (even though I listed the hemoglobin level under the diagnosis).

I tried not to let this feedback bother me because he clearly has never had a locums before. Everyone documents differently, and I consider myself to document thoroughly considering I have a nursing background. But of course, every provider has their own way of documenting and he can’t expect everyone to do it the way he wants it to be done.

Had his feedback been specific to patient management, such as “perhaps use this medication next time” or “refer this patient for a cardiology evaluation”, that would have been a different story. I welcome any criticism when it is beneficial.

Anyways, I just wanted to share my story providing coverage on my own. Maybe once you have enough experience as a traveling nurse practitioner, you can start providing coverage on your own too. Keep in mind, I didn’t need any housing or travel since the clinic was in my home area. So, there are definitely some benefits to working through an agency versus on your own, but that comes at a cost. Those benefits include completing credentialing, facilitating orientation, arranging and covering housing and travel, providing liability insurance etc. The main benefit of working without an agency will be increased pay.

Interview with Sophia Khawly – The Traveling Nurse Practitioner

I did an interview with LeaderStat, a locum tenens agency, last month. You can find the article by clicking the link above. I have also added this agency to the agency tab on my home page. They are a smaller agency but the benefit of that is you will have more of a personable experience and reasonable pay. Feel free to contact me for a direct recruiter recommendation.

 

4 Doctors and Nurses Share How They Pack for Missions Around the World

This luggage website illustrated some packing tips for medical providers traveling around the world. My tips are mainly for traveling nurse practitioners working a 3 month gig. Check out the link above for some recommendations, and feel free to browse Mighty Goods for baggage pieces.

This is something I never thought much of until recently. When I finished my first travel assignment, I remember receiving a survey that asked about my experience working with the site, working with the agency, and my housing. I soon learned that the agency also sent a similar survey to the site to evaluate their experience working with me. I think this is a nice feature because it lets the agency know if they should continue utilizing both the site and locum tenens provider.

During one of my assignments in Florida, I remember the first week the agency sent a survey to the site to ask how I was doing so far. I thought it was strange since my recruiter never even called me to see how the job was.

At the end of the assignment I was expecting a follow up survey but received none. I was surprised and also thought it necessary since I did have some constructive feedback to give. Although it may seem minute, the agency that didn’t send the survey didn’t rub me the right way. I didn’t have the personable experience I was used to getting from my favorite agencies/recruiters.

Honestly, since they never sent me a survey to evaluate the site, I felt like they cared more about keeping their business with the site than whether or not I had a good experience working there. After this, when I had the option to accept a job from them vs another agency, I went with the other agency.

Look out for those surveys and they may give you a glimpse of how much you are valued in that company.

Since the opioid epidemic is nationwide, even as locum tenens nurse practitioners, we may have to participate in this battle. I have been asked several times if there is a specific approach I take when it comes to refilling opioids during an assignment.
I’ll start by saying every provider has a different approach to prescribing controlled substances. Some are lenient while others do not prescribe it at all. I would say I have more of a moderate approach. I do refill opioids to an extent, as long as I have enough supporting documentation, and I feel the patient needs it. I also try to wean down a patient when appropriate.

For example, let’s say a patient comes in with chronic low back pain and is requesting refill for 120 tablets of oxycodone. Before going in the room I look for several documentation. Is there a controlled substance agreement in the chart? When was the last urine drug screen? Is there imaging in the chart to support this complaint? If there is no controlled substance agreement, I make sure to obtain one during that visit. I will also go ahead and order a urine drug screen. Some patients have tested positive for cocaine or other drugs, in which I let them know that I will no longer be refilling their pain medications.

If there is no imaging, I will go ahead and order that. Sometimes I am only comfortable with providing a 2 week refill while waiting for the proper workup. I will also check the PMP or controlled substance database of the state to find out when the last time the patient filled the medication. I will also check to see if the patient clinic hops to obtain narcotic prescriptions (which would be a red flag, and I would not refill for them).
During the visit I make sure to document pain level, location of pain, and failed treatments. Have they tried physical therapy? Have they tried joint injections? Have they tried non-narcotic medications? It’s one thing for a patient to say they have tried it and it didn’t help vs seeing on their chart that they did try alternative treatment and it did not lead to improvement. Most of the time, if I refill narcotics for a patient, they need to be proactively trying alternative measures. This can be specialist consults, surgery consults, acupuncture, physical therapy, injections etc.

When possible, I will refer to pain management. Especially for patients on stronger opioids like fentanyl patches, morphine, and high doses of oxycodone. However, in some areas, pain management access is limited so unfortunately, we will have to manage these patients ourselves.

I have found that if you are willing to work with a patient, the more receptive they will be. So for the patient requesting oxycodone #120 tablets, I would let them know I am not comfortable prescribing such a high amount due to risk of overdose. I would compromise to prescribing 90 tablets after they meet the requirements above, with the goal of weaning them off completely. Some patients are okay with the change because I guess it’s better than nothing, while others can become visibly upset.

This is why it is so important to have the controlled substance agreement in place. As soon as a patient becomes verbally or physically aggressive, they are breaking the contract, and you no longer need to refill pain medications for that patient.

Some other things to keep in mind are that I never initially prescribe opioids for patients. Meaning I will only refill, but not start anyone on them. In addition, I never refill opioids during a patient’s initial visit to the clinic.

No site has the right to force your prescribe opioids, but I often find that they will ask me my approach during the phone interview. If you think you will just go to a clinic and not refill any narcotics, and send them all to pain management – think again. In an ideal world it would be great, but as mentioned before, some areas have limited access to pain management, so you would have to figure out a plan for the patients you are treating. By no means am I encouraging you to follow this practice of refilling pain medication, but I just wanted to share with those of you interested, how I approach the opioid epidemic.

 

A benefit of working through an agency for a locum tenens position is malpractice insurance. In some states, such as Florida, it is mandatory for nurse practitioners to carry liability insurance. Even if it’s not mandatory, it is something locum tenens nurse practitioners should all desire to have. Since working in locum tenens is fast paced and you aren’t as familiar with a patient as their primary care provider, this leaves room for more risk.

Once I begin an assignment, I always ask for a copy of my malpractice insurance (provided by the agency or site). Then I make sure to update my CAQH profile with the liability insurance information. The reason for this is because when you accept a new assignment; sometimes the site will need all of your previous liability insurance information for credentialing. They need to verify that you do not have any current or previous claims.

Sometimes it’s annoying having to provide copies of a dozen different malpractice insurance policies. But having them already saved in a work file makes it convenient to find when needed.
I am sometimes asked if I carry my own malpractice insurance in addition to the ones provided by the agencies. The answer is no. I don’t see a need to spend a few extra thousand dollars for something I already have. Also, keep in mind the liability insurance provided is often for the entire year and not just the length of your assignment. For any specific questions about your liability insurance through the agency, be sure to clarify with your recruiter.

As I consider which states I plan on obtaining new licenses in, I am thinking about only getting licenses in states that allow independent practice for nurse practitioners. Here are the reasons why:

1. Respect: No one is calling me a ‘mid-level’. In states where nurse practitioners can practice autonomously, we are seen equally to physicians. When we are seen at an equal playing field, no one is using that term (mid-level), I despise. When I worked in Washington State before, a state that supports full practice authority for nurse practitioners, I felt respected.

2. Licensing process is easier: States that require nurse practitioners to have protocols in place or a supervising physician make the licensing process more difficult. Sometimes I have to provide a protocol before they even grant me my nurse practitioner license, which is ridiculous. Other times I have to show proof that I prescribed medications at a previous job, or obtain a letter from my supervising physician.

3. Freedom: In independent practice states I’ll be able to order home health and sign orders for my patients in need. I’ll be able to prescribe all kinds of medications without the pharmacist requesting the name of the physician I work under. I’ll be able to spend less time wondering if that’s something I am authorized to do and assume it is.

4. Better pay: States that value nurse practitioners have already progressed to allowing full practice authority. As a result, these states will typically pay nurse practitioners well. This is because other states use the term ‘mid-level’ to explain why nurse practitioners aren’t paid as well as their peers (physicians), even when doing the same work.

Some states that are considered to be independent practice states for nurse practitioners may have different stipulations. For instance, working in Washington was the ideal full practice autonomy state to work in. On the other hand, although Maine is also an independent practice state, the licensing process was still a bit tedious. I had to have a previous supervising physician confirm that I was supervised over 2 years or more, prior to them giving me an independent license. In addition, some home health agencies do not allow nurse practitioners to authorize home health orders, which I find strange. So keep in mind that the 23 states with nurse practitioner practice autonomy are not all equal.

I am so glad I chose to spend the summer in Maine. I went on a coastal road trip with a friend that visited me up here. We stopped in several cute towns on the coast of Maine, and wandered to many lighthouses on the way.

My favorite town was Camden. It was so endearing with nice views of the harbor and boats. I was able to try a Maine delicacy: lobster roll. I can’t say I am a big fan.

I really enjoyed visiting all of the lighthouses. The Pemaquid Point lighthouse had stunning views and they even allow you to go inside, all the way to the top.

We also stopped by this famous lighthouse from the Forrest Gump movie. It was even nicer in real life.

My preferred lighthouse is in Portland, Maine. It is located in the Cape Elizabeth area at Fort Williams Park. It is beautiful and I liked how families gathered there to enjoy the weekend.

A highlight of my time in Maine would definitely have to be going to Acadia National Park. There were many hiking paths, awesome views from mountain peaks, and beaches. The day I went, it was a bit cool so the beach was covered in fog. It looked like what I always expected Cape Cod to look like.

Additionally, Jordan pound was spectacular at Acadia. You can even enjoy lunch or coffee at the Jordon Pond House restaurant while enjoying natural views.

On a side note, I love being in New England because you are so close to the other states. I was able to take weekend trips visiting a friend in Boston, and exploring New Hampshire and Vermont.

My only wish is that I could remain here for fall. However, since snow fall starts as early as November I will not be extending.

There is so much provider support at my current job in Maine. It just makes our lives easier. For instance, there is an RN that handles the medication refills as long as it meets protocol (recent labs, recent appointment etc.).  When requesting a controlled substance refill, the medical assistant will copy and paste the most recent PMP report on the phone message. PMP is what we use here to look up where and when the patient last filled a controlled substance prescription.  How convenient that this information is automatically provided for you instead of having to spend precious minutes signing in and looking up the patient yourself?!

Like many states, Maine has an issue with the opioid epidemic and even patients forging prescriptions. Thus, they use a system called ‘imprivata’, which all providers must enroll in. Controlled substance prescriptions must be submitted electronically. After submitting the prescription electronically, the imprivata system pops up in which the provider must sign into. After signing in, the provider must then check her imprivata phone app and approve the prescription from there. It may seem a bit tedious but it’s a pretty quick process and at least it ensures that you are the only one prescribing controlled substances. Patients are unable to forge or change a prescription, and no one in the office is able to refill a controlled substance without your permission.

The front desk staff also handles all of the referrals. They make the providers lives easy by proposing referrals for patients. This means if a patient called requesting a referral to an eye doctor, the front desk staff will put in the referral and diagnosis, then send the proposed order to us, in which we just have to sign off on.  The RN also handles triage, so providers aren’t bombarded with ‘tick bite’ visits or patients with cold symptoms that just started today.

The only negative interesting finding I have surveyed does not have to do with the clinic staff. It has to do with the patient population. It appears that developmental delays in pediatric patients here is very prominent. Most places I have worked, you will find a developmental delay in about 1 out of 100 children. Here it seems that every other child that comes in for a physical has a developmental delay. I am assuming it has to do with the low level of education here and high use of alcohol and drugs during pregnancy and infancy.

These are just some observations I thought would be interesting to share with you all.