EP 20: Time Management for Mortals

Do you feel like time is constantly running out during clinical shifts? In this episode, we discuss creative ways to optimize the time you spend with each patient, avoiding the dreaded domino effect of visit and charting delays. Vanessa shares her go-to methods for strategically scheduling patients with complex needs, Jason explains a powerful way to self-evaluate efficiency, and Christopher breaks down the steps he and clinic staff take to streamline diagnostic processes.  

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Transcript

Christopher Gleason 0:01

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomerico De Nino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Jason Gleason 0:33

Welcome back to another episode of NP Launchpad. This is Dr. Jason Gleason coming to you with my good colleagues and friends, Christopher and Vanessa. And during this episode, we're going to talk about time management. Time management for mortals. What a great topic. Would you both say that time management is one of the most essential things that we have as far as a day-to-day practice guide goes?

Christopher Gleason 0:56

Absolutely. Absolutely.

SPEAKER_03 0:57

And if you can avoid procrastination, do it, trust me. Avoid it at all costs. You don't procrastinate, do you? I don't know what you're talking about. Vanessa, if you procrastinate.

Vanessa Pomarico 1:07

Absolutely not, because I'm one of those people that I'm always afraid if it doesn't get done and something else comes up. It's it's really it's it's terrible because I am one of those people that I'm thinking, all right, I know I have a deadline, but I'm gonna do it before the deadline because if something else comes up, I don't want to have to extend my deadline. It's terrible.

Jason Gleason 1:25

I hear you. I hear you. Yes. Yes, yes, yes. Time manager, it's such a big challenge for many of our listeners, colleagues, and friends out there. I struggle with it. I think all of us do to some degree, but we have those things in place that keep us on task, and that is going to be what we're gonna discuss during this episode. And I'm so excited, but I'm even more excited for all our listeners, colleagues, and friends out there that are tuning in. I think you'll love this episode as we do a deep dive and we bring a real perspective from each of us and what we've experienced throughout our professional careers regarding time management, and hopefully you'll have a lot of key takeaways to help you improve your time management skills as you launch into your practice or if you're changing specialties. You might have been an NP for years, now you're switching over to a different specialty. We hope that all of the information during this episode will be helpful to you because we really respect your time and we're so appreciative that you're tuning in. As before, when we shared, if you want to contact us or reach out with a question or if you have a comment, please reach us at nplaunchpad at fhea.com, nplaunchpad at fhea.com. That's how you can uh stay in contact with us. And again, we'd love to hear your comments, questions, feedback, anything you want to share with us, please do. Except your laundry. We do not do laundry, right? No dirty laundry. So as usual, our quick disclaimer: this is for educational purposes only. Where we want to be your colleagues and friends here. This is not for clinical advice or legal advice. Please seek out those professionals if you are needing that kind of advice. This podcast is all about you and building a relationship with you, our friends and colleagues out there. So let's dive into our hot topic discussion for time management. Here's our very first question. Why do NPs and physicians have challenges in running behind? And what can we do to reduce the risk of running behind? Vanessa, tell us your wonderful ideas about this.

Vanessa Pomarico 3:14

So, you know, I get really squirrely when I am running behind because I'm so mindful that I have patients that had to take a bus to get to my office or they had to get a babysitter or whatever. And it's if anybody had to ask me, you know, what is one of my worst attributes, that would be it, um, is that I don't like to run behind. So what do we do to reduce the risk of running behind? You know, make sure that you're uh you have you are in charge of your template and that you have enough time allotted for the patient visit. So one of the things that I do is I tend to go through my schedule a few days ahead of time and I'll look and I'll say, you know, who put three people in their 90s back to back to back in a 15-minute slot? You know, and so so I look ahead and then what I do is I'll say to my medical assistant, because I don't have nurses like the princes of the VA do, but I'll go to my medical assistant and just say, um, you know, could you call and schedule, reschedule so-and-so and make sure that you put them in for a half an hour? Because we know that if they're 92 years old, you know, number one, it's hard for them to get there on time. But number two, they're not just gonna come in for the rash. They're gonna say, well, you know, for the last six months, my hips have been bothering me and now my elbow hurts, and now I've been having diarrhea, and so it's always something else. Oh, so that's one of the things is always, right? So always make sure that you have enough time blocked off to see a particular patient. That's that's probably one of my biggest things I could tell people is to make sure you have that time blocked off.

Jason Gleason 4:54

You know, one of the things that drives me bananas is new patients at the VA because they're quite complex, especially a new patient you've never met before and the extensive history you have to do, not only about their physical health, but mental health as well. I love new patients, and there's so many great services we can offer them, but I want to spend time with them. And what drives me bananas, I think Christopher, you'll agree. And Vanessa, you as well. You just mentioned a lot of it in what you just uh said. But having multiple new patients on the same day drives me nuts because I feel bad, like I'm rushed and I can't spend time with them, and this is the very first impression they get of us as a provider. So it's so very important that that very first visit goes well to build that trust, camaraderie with our patients and that relationship with them. Christopher, how about you? What what tips do you have for time management?

Christopher Gleason 5:38

Um kind of going along with what Vanessa said, I sit down with my nurse and we kind of scrub the schedule together, reviewing, you know, this is this is a complex patient. They've only given you a half an hour for, you know, what are your what are your thoughts on that? And we'll go through the schedule and we'll make those adjustments if needed. Um the other thing I think is is important is to go through your alerts, making sure to get them done in a in a timely manner because they can just compound so fast, and then you're you're lagging you're lagging behind and it can feel very overwhelming.

Jason Gleason 6:09

Have either of you done a project, a quality improvement project within your clinics or practices over the years where you've actually tracked time. Like somebody had a stopwatch from the minute the patient checks in until they get to the exam room and the time they spend with you, and the nurse that checks them in and the discharge and sending them back out to the receptionist to make an appointment. Have either of you experienced that kind of quality improvement project before?

unknown 6:32

No.

Vanessa Pomarico 6:32

So actually the electronic health records does it. Um that's where they get our quality metrics from. Um and that's where they kind of push to say, well, you know, we see that you can get a physical done in 30 minutes. Okay, really, how difficult can it be on a 21-year-old? Get the 91-year-old in here, and I'll be lucky if I'm done in 45 minutes. Right. And so, you know, yeah, but so they have done that and we've used that tool as a way of being able to say, this is why we need this kind of time. I'm very fortunate where I work that we have a lot of flexibility in our templates, and we able, we are really able to run our templates the way we want it to work for us because you kind of get into a groove. Like, you know, I know that my physicals are at, you know, on the hour, you know, at 8, 9, and 11 in the morning, and then 1, 2, and 3 in the afternoon, and then everybody else kind of gets fits in between. Because I don't some days when we have all five providers there, we don't have enough exam rooms. And so we have some of us are kind of um sharing an exam room. So if I'm running behind or the patient shows up late or I don't have enough time on my schedule, then and you have two people back to back that are brand new. So we split it up so that you know we can only have a certain number of new patients, but there's always an office visit in between those two new patients. So it's not like you're running from one new patient to a second new patient. So we try to break it up a little bit.

Jason Gleason 8:00

Mm-hmm. Excellent, excellent. You know, one one of the things I would suggest our listeners uh look at out there if they're running into always being behind and time management is a big issue for them, is to look at your EHR. As you mentioned, it tracks a lot of what we're doing. But if you don't have that, and and a lot of facilities don't keep a track of it in the EHR as much as they should, ask a colleague, hey, would you mind for the next two weeks? You know, would you mind following along with me? Let's take a day out of the two weeks, for example, one day each week. And will you just follow me along with a stopwatch, whether it's on your smartwatch or on your phone, and just kind of measure a few patient visits with me? How long does it take to check in? How long does it does it take them to get to the exam room? How long does it take for me to spend time with them and the vital signs and you know the visual acuity testing and all the other things that we do during a visit? And then look at that process from a flow dynamic and how can we shave off time to improve flow? How much time do I document? Do I document on every patient before I see the next one? Or do I have a stack of charts to do at the end of the day and then I'm there for three hours at night, I'm not getting paid for that time? Look at all of those factors. One of the most profound experiences I was ever involved in was in an emergency department setting where they looked at stroke care. And we actually walked through this entire process. The patient that comes in by privately owned vehicle or by ambulance, they arrive at the ED. What steps do they go through? And as all of us know out there, stroke is like time essential that it be treated immediately because all those brain cells that are dying off. So our goal was how can we shave off time and get the patient the this essential vital treatment that they need? And what we found was it went from a process like patient checks in, patient waits in the in the waiting room for maybe a few minutes, then they're brought back to triage, and then they might be brought back out to the waiting room, and then they're brought back again, and then a nurse needs to see them in the emergency department, and then the registration clerk has to come in first because nothing can get done until they're in the EHR system. And then finally the physician or NP would go in and see them, and then they're off to the CT scanner to see if they've had a hemorrhagic stroke or if it's an ischemic stroke, and if it's not hemorrhagic, then they're gonna get TPA, but the TPA has to come from the pharmacy, which is three stories above in this large building, and it has to come down to them. And it goes on and on and on. But we looked at this process, and we shave so much time off door-to-needle time, which is essential for all of you out there that know that that have dealt with stroke or treat stroke. It's so essential that we shave time off that. And they went from, you know, up to an hour to 90 minutes down to like 27 minutes door-to-needle time. And what it changed was rather than have the patient check in and go to the exam room and the nurse see them first and then registration and the physician and all these steps. What they do now is the patient comes in on an ambulance, they skip going to the exam room. They go right to CT scan to look and see if they have had a hemorrhagic stroke. Nope. They they've consulted with neurology through telehealth, they have obvious stroke symptoms, they give them TPA while they're in the CT scanner room itself and saving all those brain cells. So that's in an acute care setting for our NP colleagues out there that might be working in that kind of setting, is so helpful to look at that flow process. But even in primary care, to do the same thing and just have someone, you know, not every day, because that that's labor-intensive, but maybe over a few weeks, at least two weeks, maybe a day out of that time, get a colleague to time you or you time yourself in some way, and just look at the flow process and where you can shave time off, save time, because that's going to truly save your sanity, right? It's gonna save your sanity ultimately. I know it would mu it would for me, but that's just a tip that I would provide for our audience out there. Any other tips or suggestions on how to do time management effectively?

Vanessa Pomarico 11:39

Well, you know, time management is one of those things that I always say to students, you know, I can't teach you time management. You know, I can teach you how I manage the day, but everybody really has to figure out you know where their weaknesses are and what they need to do. And you know, I can't teach somebody to write faster. Um but they do have to be able to look at something and be able to complete the notes rather than taking, you know, all this time. And like you said, are you gonna stay there for three hours after work? I like both of you, you know, we come home from work and what do we do? We jump on a meeting or we're we're recording a podcast. So, and I always say to the students, listen, I have to be out because I've got X, Y, and Z to do when I'm outside of the office. So we have to work on this. And most of the time when I have a student with me, they start to pick up some of those time management tips. What they do when they go out is something entirely different. But it it I have to tell you, I just don't understand when I I hear colleagues that say, Oh, I'm going into the office this weekend because I haven't I've got about three months worth of charts to do. And I'm glad you reacted that way. But I don't know about you, I can't remember what I did an hour ago. No, I'm gonna remember what I charted three months ago.

Jason Gleason 12:52

And those are the times something's gonna happen and then lawyers are gonna have a heyday with you on the stand, right? Yeah, because you're winging it. You're winging your documentation and it's called fraud, right? You're making stuff up because you we can't remember. Yeah, it's just not safe.

Vanessa Pomarico 13:05

I think one of the things And not only that, there's timestamps on on electronic health records.

Jason Gleason 13:10

So if anything is an attorney looks at that, they look at it. Exactly.

Vanessa Pomarico 13:14

If it gets called into court, they're gonna say, Well, this patient was here February 2nd. Why did you document on May 15th?

Jason Gleason 13:20

Yeah, exactly. Yeah, and then if you say, Well, I have like photographic memory, I can remember all this, they'll ask you the next question is okay, what did you have for lunch two weeks ago? I don't know.

unknown 13:30

Right?

Jason Gleason 13:30

I mean they'll they'll get you, so do not lie through the process.

Christopher Gleason 13:33

Exactly. Right. I think one other thing that can help with time management too is huddles in the morning. I find that to be valuable because I will meet with the the nurse um that I work with. We'll go down the list of patients that we're seeing for the day, I'll consult with the RN as well, and we'll just kind of go down the list one by one and say, hey, this this uh veteran is here for this. What do we need for this? Is there anything that we should know before the visit? Is there anything that I should do to prepare for the visit? And I think that is a huge thing in in uh time management.

Jason Gleason 14:03

Excellent, excellent, I agree. Our next hot topic. You ready for this one? When the day starts falling apart, when the day truly falls to shit. Sorry, we need a swear jar. I feel bad. I'm out of place here. We need a swear jar, Chris. For the case, but when your day starts falling apart or to crap, how do we reset without compromising patient safety? What do you do, Vanessa? Tell us.

Vanessa Pomarico 14:25

So I usually, you know, when things start falling apart, I have to look at, all right, well, what has happened? Has there been an accident? And that's why everybody's showing up late. Is it case in point? I'm gonna tell you this right now because it just popped into my head. Last week, I have a patient who is always makes the 1145 appointment. My staff goes to lunch at 1215. She always makes an 1145 appointment. She is always late. I could bet my license she's not gonna show up on time. Well, we had a meeting with uh some of the higher-ups at 1215. And I knew if she showed up at five minutes to 12, I wasn't gonna be done by 1215. So I had my medical assistant call the patient to say Vanessa has a meeting that she needs to be at, so you need to be here on time at 11:45. And the patient showed up at 11:40. So I got an extra five minutes. But even still, I think you have to kind of take the bull by the horns and just recognize, you know, those patients who are notoriously late, or if that's not the case and you need to kind of reset the day is just falling apart. I just kind of sit, we do another huddle with my medical assistant and my receptionist to say this day is falling apart. How can we kind of pull this together? And then usually if it's a room issue or you know, the patient, whatever it is, we just kind of look at it, we brainstorm, and then we go, okay, here's the plan, and then everybody has a job they execute.

Jason Gleason 15:55

Love that. Love that. Love that. I think one thing that takes a lot of time for our folks that check our patients in for us, if we have those out there, are the reminders in the EHR. So when things are really falling apart, I'll I'll ask my uh professional colleague, I'll say, gosh, when you're checking in patients, just do the essential ones, right? You don't need to go down the list of 20 things because that can take a long time, but just focus on the vital things we need today. I agree. I think huddling with your team throughout the day is so important. Definitely.

Vanessa Pomarico 16:21

You know, one of the other things too is that when things start to fall apart, you had just said that about you know, asking the essential questions. One of the nice things is that when patients actually take advantage of the pre-check-in and they go through their list of medication, you know, they do their own med reconciliation, they do their own, you know, here's the update or here's what I want to talk to you about, so that in the morning when I'm prepping, you know, for the day and kind of going through and getting my notes ready, I'll see that the patient has already requested that they want to talk to me about X, Y, and Z. So I'm prepared before I walk in the room. And I think that's uh another one of the bonuses of that pre-check-in that patients can do.

Christopher Gleason 17:01

Excellent. I think another thing that can be beneficial too is uh with my nurses if I'm seeing a a patient for you know image reviews. I'm reviewing an MRI with them, I'm reviewing an X-ray with them, what have you, they'll print it out and they'll have it on my desk. So I don't have to go into the EHR searching for it, which is a huge, huge um time saver for me.

Jason Gleason 17:21

Yeah. On those busy days where things are really stressful and you're falling behind too, I think it it sounds counterproductive or intuitive, but I think it's so important you also protect the guardrails of the day, like your lunch time, your administration, administrative time. Try not to work through lunch. Sometimes it's impossible, right? Reality sets in, and it's just a crappy day, and you have to work through lunch and your break time and all that stuff. But you're not gonna be good to anybody if you're not good to yourself, right? Even if it's for a brief lunch break, instead of 30 minutes, maybe it's 15. But you've got to have time for yourself. You've got to put up those guardrails and the boundaries and say, you know what? I need a break, I need to walk away, I need time by myself for 15 minutes even, and take that time because it's gonna be well invested. You'll be better at what you do.

Vanessa Pomarico 18:05

Yeah, you know, I have to tell you, during the pandemic, um, I really, you know, I have a uh a special a specialty in uh self-care, especially self-care for healthcare professionals. But during the pandemic, when we were really stressed, and you know, every 10 minutes it seemed like something was changing. I would bring my ear pods to work and I would go sit in our lunchroom, and even if it was five minutes or I remember there was somebody in our lunchroom and I sat on the steps. We have you know back stairway in our building. I sat on the steps and I did a five-minute meditation. I didn't have a lot of time to go out and take a walk or kind of decompress. It was one of those days, and I was like, uh if my mind starts to fall apart, I'm not gonna pull it together. So I just excused myself. I went in the back, I did a five-minute meditation, just some breathing. I kind of reset myself and I was able to go back into the disaster, and it wasn't such a disaster because I took time just to reset me.

Jason Gleason 18:59

I love it. Yeah, I love it. And going for a walk. I I know at our clinic during the the summer months or the the warmer months or parts of the year, walking outdoors is great, even if it's short around the block, right? Just do something, keep your body moving, relieve that stress. But in the winter months, it's kind of a challenge because you're not gonna walk in 40 degree blow below weather, right? And so why not? Yeah, we've tried, we've tried. Yeah, frost frostbite sets in pretty quick. But um, but you know what, it's so funny at our clinic, what a lot of our our colleagues do, our nurses, and and I know Christopher and I do this as well, is we go out to our cars and it's like a a pod. Yeah. A stress-free pod. Put on your music, relax, turn on the heat, you know, and just chill. Yeah, and and meditation or whatever you need to do is a good reset. So I agree.

Christopher Gleason 19:46

I definitely try and take and take the time during my lunchtime to just step away from the computer. Even stepping away from the computer can be such a huge relief for you. Because you're you're just, you know, you're you're protecting yourself. Like Jason said, we go into our cars, we'll listen to music, we'll just it's just that space to chill, just that space to get away from the clinical environment for enough time to be able to go back with you know with that fresh uh mind and saying, okay, now I can deal with what's what's next.

Jason Gleason 20:11

Absolutely. And do not, by every means, do not, absolutely do not, have a flask of whiskey in your bottom drawer of your desk. Right? Do not do that to relieve your stress. Yeah, yeah. All right, moving on. Let's talk about this. Fact or fiction, my favorite part of our episode, factor fiction, where we try to stump each other. We've been pretty good at this, though. So being constantly available makes you a better clinician. Christopher, fact or fiction.

Christopher Gleason 20:41

Most definitely fiction.

Jason Gleason 20:42

Excellent.

Christopher Gleason 20:43

You have to, as a clinician, you have to learn to say no. If if your job is w is consistently asking you to work after hours, you know, we kind of touched on this a little a bit ago about those hours that you're not getting paid for, but you're being asked to, you need to say no, you need to set those boundaries.

Jason Gleason 20:58

Yeah, work-life balance, right? Work-life balance. All right, Vanessa, you ready? A template, a template tweak of five minutes can change your whole day.

Vanessa Pomarico 21:08

Oh, I I absolutely. You know, you don't think that five minutes is a very long time, but if you just tweak it by a couple of minutes, it really can just give you five minutes where you can maybe finish up with another patient, you know, take a sip of coffee, whatever you have to do. That that five minutes can make a big difference.

Jason Gleason 21:29

Excellent. And only five minutes, and sometimes that's all it takes. That's all you have, right? Right. Yeah, take some time to yourself. All right, Christopher, wrapping up this this uh segment. If you're behind, triaging is safer than rushing every visit.

Christopher Gleason 21:43

Absolutely, absolutely.

Jason Gleason 21:44

And how would you do that?

Christopher Gleason 21:45

Give us an example for me, it would be going through kind of this what I um said earlier about going through the visits with my nurses in the morning and saying, you know, okay, we have a full schedule today. I know this patient's gonna take. This amount of time, this patient's going to take this amount of time, or at least a good guesstimate of how much time to spend with each patient. And I think that's that's crazy, that that level of triage is key, especially uh in those cramp days.

Jason Gleason 22:10

How would you both handle like an office emergency? Let's say a patient shows up for their 15-minute appointment, but it turns out to be a three-hour visit and they're crashing or you're calling the ambulance and you're so far behind. Let's say you're two hours behind. And that's not often that that happens. I think it's happened to me once in the last few years. But do you ever pull the nuclear button and say, you know what, we need to reschedule some of our patients?

unknown 22:32

Absolutely.

Christopher Gleason 22:34

Absolutely. And I think just having that conversation with the patient themselves, too. You know, when you when you go to reschedule, you know, I'm so sorry, but I I have, you know, I had an emergency that I had to take care of. I have gotten behind. I'm now behind two hours. You know, I really won't have the um the time to spend with you that I want to spend with you for your for your visit. So, you know, can we reschedule it? I think that's important. And in just acknowledging their time, you know.

Vanessa Pomarico 22:58

Or even the patients in the waiting room, you know, if I'm running behind and we've had an emergency, that you know, I've I had a patient that came in for a blood pressure check and they were having an MI in my office. So that 15-minute blood pressure check suddenly turned into, you know, an hour visit. Um, but I said as I knew something was going on and now I'm gonna need to get the EKG. That the patient was sweating and they were very pale and they weren't, they really were not well. Um and so what I did was I just said to my medical assistant, please go and tell the patients in the waiting room I'm running behind and give them the opportunity to come back. And I, you know, I'll stay later today, or you know, I'll sometimes I've gone in on my day off if I've had to, you know, really cancel a lot of patients. But the patients appreciate the fact that it's easier to give them that option. If they want to wait, they can wait. Um, but also too, ask your colleagues, you know. Uh, you know, I've got somebody who's having an MI, you know, I'm running a little bit behind. And I have to say I work with, I love the people I work with because whenever we all jump in, so if it's not me and it's somebody else having the emergency, I'll just say, I'll see your next patient. You know, they're here for a sick visit anyway, it doesn't matter who they say. Um and so just, you know, remember that when somebody when one of your colleagues is is rushing and they're running behind, that you know, you might be able to jump in and help them out a little bit.

Jason Gleason 24:21

You know, one thing I appreciate about the VA, and again, we kind of set the stage for the rest of the country as an ideal format for a great healthcare system at the VA. And there's so many good things about it. You know, one one one of the greatest things I think that they've recently done is they have gap providers in a lot of primary care clinics. And I'll tell you what, they are a lifesaver. Absolutely. Absolutely. Yeah, truly. They handle a lot of the walk-ins that come in or fill in if we're being pulled in a different direction to handle an emergency or something. Yeah, it's such a great service.

Christopher Gleason 24:48

So and sometimes they'll even see like our post-hospital discharge patients, so they'll they'll see those, which can be a huge, you know, kind of a huge weight off our shoulders. Because meanwhile, when when we have these post-hospital visits, we have you know annual visits and we have new patients and we have change of provider patients. So that can be a huge help to us.

Jason Gleason 25:06

Yeah. And it's not so much a luxury for us, it's like a patient safety issue, right? So we can provide good care to our patients. So that's ideal, but that doesn't happen everywhere. I understand that. So the great points on all of that information there. I want to do an important plug for all of our listeners out there, and you've heard this at every episode, but this is a great, great benefit. So make sure you take advantage of this. We appreciate all of our listeners, and we'd like to share some special savings with you. Visit FHEA.com and when you do, use the code LONCHPAD20. Launchpad 20, all one word, launchpad 20, for not 10, but 20% off all CEN memberships. That's a huge bargain. So make sure you take advantage of that. And again, we just want to give you that gift, that treat to you for listening into our show and all of us at Fitzgerald Health Education Associates by Calibre. Appreciate every single one of you out there. Going on to our mailbag, let's see what kind of questions you had over the last week. Here's our very first question from our mailbag. What keeps you late most often at work? Charting, your inbox, add-ons. What kind of things keep you in the office, Vanessa?

Vanessa Pomarico 26:17

So I I have to say my charting is not an issue because as I've mentioned before, I use dot phrases and and templates, and so my my charts are closed by the end of the day. Um I can't say that I do we do add-ons because we're very fortunate we have a walk-in, you know, right around the corner, or one of our sister walk-ins. Um I would have to say it's the inbox and the paperwork, you know, the FMLA paperwork, the endless, you know, signing of the PT papers, or it seems like every day, uh, you know, for the same patient, I get something from the visiting nurse that I have to then go through the med reconciliation and sign, you know, whatever they're doing for home care. It's the paperwork that I think that's what keeps me there. Like I look at and I I say to my medical assistant, she'll come over and like she'll have the folder and she comes over and she puts it on my desk just as I'm leaving. I'm like, you couldn't give me that an hour ago.

Jason Gleason 27:11

Come on. Come on.

Vanessa Pomarico 27:13

But again, setting boundaries. So what do I do? I flip through it to make sure there's nothing important. I'm like, this can wait till tomorrow. And I leave the office. So I I give myself my own boundaries, but it's definitely the inbox and the paperwork.

Jason Gleason 27:26

You know, you you'll have our new NPs out there know this. You've already been probably hit with this already, like Vanessa said, is the paperwork and all the things you have to sign. Usually we run into like physical therapy and different home services we have to sign. And there's a stack every week. You think you're getting ahead and then you're so far behind again. But one of the things that I've done in my practice, and I'd recommend folks out there consider is every Wednesday we have admin time. So I have a folder, it's a blue folder, and uh, and I tell them put anything I need to sign in this folder and I'll sign it once a week. That's my boundary, rather than have it come to me every day. Now there is a stack, like I have 50 things to sign, but I also have the time set aside to do that. So that's my boundary, which I'd recommend for our listeners to consider. Christopher, do you have anything?

Christopher Gleason 28:10

Not with regards to that so much. For me personally, um when I have those those forms to sign for PT, for home health care, things like that. I have set up a system with my with my nurse that you know she presents them as they come in. And she'll catch me between patients or whatever, and I'll just sign them really quickly. And then that way they don't compound for me, which is which is really helpful for me. And then during that admin time that you spoke of, you know, I can focus on you know my alerts and and contacting patients with results and things like that.

Jason Gleason 28:38

You know, regarding paperwork, have you guys been uh hit with the the, I'd say a blizzard of paperwork regarding the GLP1 and GLP1 GIP med prior authorizations? Vanessa, have you experienced that?

Vanessa Pomarico 28:50

So we're not doing any of that in our office because we are chronically understaffed. Um but our our health system, yes, well, first of all, we have a certified diabetes educator who's amazing. Um and I have to tell you, I think I manage about maybe a dozen diabetic patients. The rest of them all go to our CDE. But also, too, our pharmacy, our our our um, you know, our pharm Ds, if I put the referral in, they take care of everything, which is that's been great. Because even if the patients don't want to see the diabetes educator, which I like them to do because she can get the sensors and she has the time to teach them. But the the the GOPs with all that paperwork, the farm D takes care of everything. I just have to put the referral in and then I just have to sign the order. So it they really streamlined it because, as you know, that mountain of prior authorizations that we have to do, not just for the GOPs, but I had a patient that was statin intolerant, a young woman, and you know, her triglycerides were over 500, her LDL was over 200, and she was statin intolerant, and Zedia wasn't touching her. So she's a really great candidate for one of the other ones, you know, the small interfering RNA or one of those. Um and so I I've had to jump through hoops to get the prior authorizations done with that. But it gets done.

Jason Gleason 30:14

And it's so vital. I mean, it's life-saving for our patients, right?

unknown 30:17

Yeah.

Jason Gleason 30:18

One of the things with the GLP1 and GIP, and I know our our focus for our podcast is not clinical, but this is more administrative. One of the tips I would share with our folks out there, because you're gonna be blasted, because finally, finally, science has caught up to where we've been telling our patients for decades, well, if you just get off the couch and move more and eat less, you're gonna lose weight, right? That's horrible. That's terrible care for our patients. But that was really one of the only answers we could give them. But now that we understand more about obesity and that most patients with obesity or overweight conditions are low in GLP1 and GIP hormones in our body, and the medications, the blockbusters we have now are a replacement or a mimic for that. It's such a wonderful time in medicine and nursing because we're finally able to help them, help them through their horrible uh experience that they've had with obesity and overweight conditions for decades of their life. So I'm excited about it. But because of the cost, as all of us know and our listeners know, there is a mound of paperwork that has to be filled out for prior authors. So here's my tip for you for prior authorizations, because out of all the medications out there, I think this one is one that will bombard you with requests. And like Vanessa's practice, they have somebody devoted to work through that process for them. A lot of you may not have that. So here are the tips that I will give you to work through the GLP1 and GIP medication prior authorizations. Number one, most insurance companies have a form that is easy to fill out, like TRICARE, which we deal a lot with, Blue Cross Blue Shield, they all have their own form because they know how big of a deal this is. So they have their own form for the GLP1, GIP meds out there. They're very specific and they're pretty easy to fill out. Like the TRICARE form I love because you just check a bunch of boxes and it says, you know, if your patient meets this criteria, check this box. And if they don't, sorry, stop here, they don't qualify. And you you complete the form, send it in. But here's the deal with the GLP1 and GIPs that I have found out. Insurance companies, prior authorization is a piece of cake, honestly, because patients meet the criteria most of the time. And if they don't, you'll know that even before you fill out the form that they that they won't. But you submit the form, insurance says, yep, we're gonna cover this drug that's normally $1,400 out of pocket without all the special discounts that they offer, just straight across $1,400 a month out of pocket. We're gonna cover this drug. But your insurance has it rated as a tier two instead of a tier three, so that means that you're gonna have a higher copay. Your patient is so excited to start this medication, but they go to the pharmacy, yep, we your insurance will cover this, but you do owe a $650 copay. Crazy. Nobody's gonna pay for that, right? And so they come back to you deflated, discouraged, maybe angry even. It's like, well, gosh, I thought I was gonna start this medication, but now I can't because there's no way in heck I'm gonna be able to afford $650 a month, you know, uh copay under my insurance. So here is a big tip that I found out that saves so much time because otherwise you're gonna be just racked with these requests over and over again and all the issues with them. When you submit for prior authorization for a GLP1, GLP1 GIP combo medication, number one, go to the insurance website and get the form to fill out. Fill out the prior authorization form, submit all that information, but here's what you also have to attach to it. And I had no clue about this. An insurance person told me about this form. It's called the tier exception form. Tier exception form. And it's kind of a myth out there that you request a tier exception if they have a hard time paying for their medications, like income-based difficulties paying for their or income hardships in paying for their meds. It's not that at all. The tier exception form asks no financial information about the patient at all whatsoever. You as the provider are just requesting that the insurance company move the tier two medication, where you have a huge copay, like $650 a month, down to a tier three, which may be like a $25 copay a month. So what I do is get the prior authorization form, complete that, but attach to that this tier exception form, which every insurance company out there, I should say most insurance companies out there should have available on their website as well, but you've got to hunt for it. Fill out that form, and much of the time the prior authorization form and the tier exception form have the same information, it's just a different form. Submit all of that in a packet to the insurance company, and it's all done together. That way you don't have a patient coming back to your office all the time. Well, gosh, now I have this excessive co-pay, I'm not gonna be able to afford this, and then you have to submit the tier exception form at that time. Submit it all together at the same time, you get it approved, you're done. And then you just have to deal with the refills because most insurance companies will approve those medications for about six to twelve months, and then you gotta go through the process all over again, which is kind of a headache. But that'll simplify the flow for you. Any any tips or advice, Chris?

Christopher Gleason 34:59

Not really. I mean, exactly what you said. I mean, filing for that tier exemption is key. Making sure they submit all of the information at once is key. But even with that, I think sometimes you'll still get a little bit of pushback from the insurance companies at times. I know I have, you know, personally as a practitioner. Yeah. But just kind of you sticking to your guns and resubmitting the information that they request. It can be a tedious process, but in the end, you know, a lot of the times you'll get uh authorization for it.

Jason Gleason 35:22

Yeah, absolutely. Any final thoughts on that topic, Vanessa?

Vanessa Pomarico 35:27

Just document, document, document. So when the insurance company says fax us your notes, you have in there that the patient has tried and failed multiple diets, you know, they have uh, you know, a BMI of whatever, um, and have everything documented in there so that this way when the insurance company looks at the notes, it's one less thing that they're gonna say no to as long as it's documented in your office note.

Jason Gleason 35:53

Yeah, build the case and be a thousand percent honest because they will find out if you're not. Absolutely. They will find out if you're not. All right, another question we have here. What's one task you could batch or delegate to others but have not done so because we're control freaks? Anybody? I know I've had that issue. Christopher, how about you?

Christopher Gleason 36:11

I don't really have this issue because I'm not afraid of delegation. Um so I will deliver delegate responsibilities to my to my nurses as, you know, according to whatever their whatever the license um licensing allows them to do. So I don't really have an issue as far as delegation goes.

Jason Gleason 36:27

Like what task would you delegate to somebody like a practical task? Can you give us an example?

Christopher Gleason 36:32

Um Let's see what would I tell it. Um like reviewing of lab results. If I have lab results or imaging results that are, you know, they're all within normal limits, things like that. I'll often ask my um my RN to to review those labs, you know, with a patient instead of relying on me to review it with a patient. And that's well within their scope of practice.

Jason Gleason 36:47

Like when they're calling with the results. Yeah, I do that too. And then I'll put on the order though for return to clinic for like a phone visit to review labs for you know the nurse to do that, but then I'll also put in the order, please alert the NP if any abnormalities are there. And then I'll call the patient, right? But if they're normal, I I do that. How about you, Vanessa?

Vanessa Pomarico 37:05

Yeah, same thing. You know, don't be afraid to delicate. That's that's really part of what's going to help with our workflow so that we don't get caught up. Because let's face it, how many times do we call a patient and we'll say, Oh, you know, your lipids are fine, you know, repeat them in six months, stay on the same medication. And the patient will say, Oh, you know, how's your husband? How's your dog? Are you taking any vacations? Like, I'm not here to chat. Like, I got you know, 25 people waiting for me. No. Um, so so really delegating all the normals, like you said, being able to have my staff call those normals. That was hard for me to give up, but I realized they're qualified to call somebody and say, this is normal, repeat your labs in six months.

Christopher Gleason 37:48

So reflecting on back to what you said earlier, Vienna, when you're on the phone with them, oftentimes you'll get the and then question too. Oh, yeah. You know, the inevitable and then question. Oh, and why why have you on the phone when I want to discuss, you know, my hip that's been hurting for six months, the pain in my my knee that I've had for you know two years or what have you.

Jason Gleason 38:06

And and what and to be fair to them, I mean, they don't know how busy our day is, right? And and they they're probably wanting, well, I better talk about this now because then I'll I'll forget it, my visit or something like that. It comes from a sense of you know, just wanting to be helpful for themselves and for us. But sometimes it's not though. Sometimes there's a little manipulation there too. You gotta utilize all our time. But yeah, such great points, such great points. You know, I would say for our new NPs out there that are just going to a practice from day one, you have to own the moment, recognize that you're the team leader. Don't go in there like an arrogant boss, right? You don't want to be that curmudgeon provider. But really also don't settle for less. Like make sure that you have somebody working with you on your team. I've seen new NPs go into a practice where they're it. They're the nurse that checks in the patient, they're the provider that sees the patient, they do everything, and then they discharge the patient out of the office, take them up front. They do everything, but make sure you know your boundaries and ask, even during a job interview, who's gonna be working with me? Do you have a team approach or am I it? Right? Are you gonna be expected to be the entire team, the nurse, the receptionist, and the and the provider? Because some provide some clinics would do that to you. They see you as a nurse that can do it all, right? And it costs savings to them. Don't go for that. I would never take a job in that kind of instance. But other things you want to look at, I would say from day one, is like during your annual visits, who's gonna do the visual acuity exam? Should you be doing it during your 15-minute chunk of that appointment? Probably not, because you have other things you have to focus on. So I what I would do and I do in my practice is ask the person that I'm working with to kindly get the visual acuity during the annual visit with the vital signs, right? Yeah, do those kind of things. But delegate that out and talk with your team, but be very kind. I think I shared with a previous episode. Do not go in there with a God complex. You know, I'm an NP now, I'm no longer a nurse because they will walk all over you from day one to do that.

Vanessa Pomarico 39:56

And you'll lose their respect. Oh, yeah, absolutely.

Jason Gleason 39:58

And never use the words, I don't have time for this. Can you please do this because I don't have time? Because guess what? They don't have time either. They don't have time either. So you gotta be very careful how you talk about these things. But yeah, delegate and don't be afraid to do that, I would say. All right, so our wrap-up landing checklist for you at home listening in. So here are a few key tips you want to work on. If you're running, if running behind is often a workflow problem, not a personal failure, look into that and analyze those circumstances and see where you're at. Kind of check yourself and work through those processes. Remember that your calendar is a clinical safety tool, not just a list of appointments, but it's a clinical safety tool to look at and to use every single day. When the day falls apart, triage instead of rushing every visit, because you're gonna miss something, and that's gonna be a big deal for your patient for their safety and a big deal for you liability-wise. So when the day falls apart, triage. And you know, we talked about the nuclear option of rescheduling patients. You don't want to use that often because your administrative staff will not like that at all, and your boss will come down on you very hard if you're using that and abusing that. Like I said, I've used that option maybe once in in years, right? So it doesn't happen very often. But don't be afraid to use that if you truly are running behind and it's be beginning to be a safety issue for you. Protect complexity slots for new patients, chronic care, where they have a laundry list of health issues, mental health appointments, certainly that they can take a long time, procedures and high-risk follow-ups. Vanessa, how much time do you allow for a women's health visit where you're doing the GYN exam?

Vanessa Pomarico 41:28

45 minutes.

Jason Gleason 41:30

45, yeah.

Vanessa Pomarico 41:31

Yeah, because I treat it like a regular physical, an annual physical. I still have to ask them all of the usual questions, but then I have all of the GYN related questions that they need to be asked. So I block all 45 minutes for it. I they give them their PAP, they get their their mammogram, I mean their uh their breast exam and you know, all the orders. So it's it's still a physical exam, it's just more women's focus. So 45 minutes.

Jason Gleason 41:55

45, excellent. And that's what we do. We do the same at the VA with our patients. They allow us that. Some NPs out there might get pushback from administrative staff. Like, why do you have all these 45 minutes? I believe a good response to that would be it's about patient safety and it's also about reimbursement. And remind your administrative staff that you're being reimbursed at a higher rate for these longer appointments. It's more in-depth that I'm coding higher. So get off my back, right? Patient safety and reimbursement. Kind of push back a little bit because you will be you will be pressured to see patients maybe every 15 minutes in some areas, and that's that's not right. So stand up for yourself. All right, other key things you want to consider debrief delays so you can fix the system. So when you have a crappy day, when everything falls apart, analyze it. Just don't blow it off or forget about it, but really analyze it. Maybe consider a flow, kind of a flow diagram or a flow study, a mini quality improvement project, taking a day out of your week to kind of time things, to look at the day and how it how it flows to see where you can trim time and save time, not only for your patients, but for yourself. So your homework for this week. Here's your homework. So write this down, everybody. Track your actual visit times for two weeks and compare them to your schedule template to see if you're staying on task. And again, as I mentioned before, just a few minutes ago, and we talked about earlier, you know, look for those times that are time wasters and where you can shave time off your day to save your sanity and save your patients, right? And then I also want you to identify one recurring delay in your clinic day and ask, what is the system fixed for this? So look at those two things. Look at flow, and then what are the time wasters in your day and how can you fix those? So those are your homework items for this week. As we close up, I want to ask you to do several things for us. Again, number one, thank yourself for investing the time and listening to our podcast. We so appreciate you and we want you to get a lot out of this podcast every single episode. We hope that you're helping us and we want this to truly be a five-star experience. So thank you for tuning in. Please drop five stars. If you think we earn five stars, please give us uh the five stars because what that does to our podcast, it raises our visibility, which means we can affect more NPs out there and bring them into our community. Because when we we we do that, we build our community up, which is gonna build every single NP up out there. We want to do that. Hit follow. The more people that follow us, it does the same thing. It builds that momentum for our community. It's not about Jason or Christopher or Vanessa or this podcast, it's about you. And we want to build this community to help each other out. And we honestly learn as much from you as hopefully you learn from us. Also tap subscribe because you get added benefits from doing that, including show notes and other information that will be shared with you. And speaking of share, please share this podcast with all your friends, colleagues, whether they're NPs, nurses, physicians, soon-to-be NPs, if they're still in high school and they just want to learn about becoming an NP, share it with everybody, even your grandparents, share it with everybody out there because again, we want those folks tuning in where we can really make a difference in their lives and where we can help each other. So thank you so much for tuning into our episode. We look forward to seeing you again. Thanks.

Christopher Gleason 45:06

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