AANP Member Spotlight: Starting a Virtual Practice
By Adam Schragin, AANP Communications Writer and Editor
Joshua Hamilton, DNP, APRN-CNP, PMHNP-BC, FAANP, was an early adopter of the telehealth technology that has become so commonplace in health care today. He now works completely via telehealth in private psychiatric practice in Las Vegas, Nevada. Hamilton spoke with the American Association of Nurse Practitioners® (AANP) to offer insights for nurse practitioners (NPs) who may want to begin their own telehealth practice and to discuss his early experiences at the intersection of patient-centered care and technology.
Q: What advancements have you seen in telehealth over the last few years?
Joshua Hamilton: Telehealth improvements were initiated well before the pandemic, but we did see a real escalation of the timeline. My electronic medical record (EMR) vendor had been talking about a telehealth option for eight years. It wasn’t until mid-to-late 2020 that they actually said, “We’re going to deploy this. It’s probably not ready for primetime, it’s still buggy,” but that’s when we actually saw what I believe was the first integrated telehealth option within an EMR.
We did see a big escalation in terms of how fast things changed. There were a lot more integrations that came out, a lot more one-touch stuff and a lot more attention to the patient portals. Payment, the ability to pay with online payment systems or with a credit card — they really doubled down on some of those layers of features in mid-to-late 2020.
Q: What advice or information could you share with entrepreneurial NPs interested in starting and maintaining their own telehealth practice?
Hamilton: Take your time, and really vet your options. We have so many proper telehealth services. Really take some demonstrations and find out what — for your price point — will a vendor be able to do for you in terms of integration of scheduling, documentation, conducting the visit, any follow-up you may have, any portal relationship in terms of documents being exchanged, data being exchanged, payment information, referrals, education … it’s amazing what we can deliver asynchronously now for patient education via telehealth. Use this opportunity to envision a different way to interact and enrich the patient encounter that probably transcends what you’re used to.
The world is getting really creative, so reflect on what you want to look like in the virtual space. Consider your volume of workflow, your bottom line and your margin. A lot of people get sticker shock looking at the cost of some of these software solutions, but what I have found in the last few months is that a lot more of the commercial insurers are paying for this type of visit, and sometimes reimbursements are actually more competitive.
Q: We’ve heard about the positives of telehealth, but what struggles have you encountered?
Hamilton: There are two things — and they’re still there — for me as a psych mental health provider. First, what do you do with a patient when they appear on camera and they’re not doing well? Do you have a contingency plan? Do you have those touchpoints for a welfare check? How do you get someone to go out there and check on a patient who is not at the camera as scheduled, or someone who is making statements or appears in a way that gives you a real bona fide concern about them in physiological care? With crisis care and critical situations, you need to map that out and think it through before it happens.
The other is that word of mouth is important — especially for NPs — and if you’re good at what you do, and your webside manner is good, people will call you from adjacent states or states abroad. Licensure is still a real sticky wicket, especially for NPs. It’s costly to really think about how many patients need to call me from Idaho and want to see me before I can justify an additional license — the time and trouble it takes to apply for licensure in potentially 48 states. I guess in some instances the latter one is a good problem to have, but it’s still a real problem.
Enroll in a Free Webinar to Discover the Latest Breakthroughs in Identifying and Treating Hypoglycemia
By Alex Fernandez, AANP Content Marketing Specialist
Nurse practitioners (NPs) are leaders in educating and caring for patients with diabetes. Hypoglycemia is a dangerous condition that can affect anyone with diabetes who is treated with insulin preparations or oral insulin secretagogues. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), “Four in 5 people with Type 1 diabetes and nearly half of those with Type 2 diabetes reported a low blood sugar event at least once over a four-week period.”
In the last 20 years, the number of adults diagnosed with diabetes has more than doubled. On top of that, more than 1 in 3 adults has prediabetes. Yet, more than 80% of those adults don’t even know they have prediabetes and are at a high risk of developing Type 2 diabetes, heart disease and stroke. You can help turn the tide on this disconcerting trend by raising diabetes awareness in your community. Help overcome therapeutic inertia in Type 2 diabetes with this practice tool that offers effective strategies you can use to talk your patient through their wellness plan. Explore additional clinical resources on endocrinology from the American Association of Nurse Practitioners® (AANP).
In 2018, approximately 17 million adult emergency department visits were reported with diabetes as a listed diagnosis. Of these visits, 242,000 were for hypoglycemia, while 248,000 were for hyperglycemic crisis. Although hypoglycemia has a variety of causes and symptoms, patients with diabetes are at high risk for hypoglycemia if they:
- •Use insulin, especially if they have been using insulin for a long time.
- •Use diabetes medications called sulfonylureas (glipizide, glimepiride or glyburide) or meglitinides.
- •Miss or delay meals.
- •Have liver or kidney disease.
- •Have had previous hypoglycemic episodes or experience hypoglycemia unawareness.
AANP is here to help you and your patients prevent, prepare for and treat hypoglycemia. Share this helpful flipchart on controlling glucose levels, designed for your patients with Type 2 diabetes, and review this hypoglycemia tool with your patients to teach them how to prevent and treat low blood sugar. Remind them of the three vital strategies to successfully treat their hypoglycemia:
- 1.Use the 15-15 rule: Consume 15 grams of quick-acting carbs and check your blood sugar again in 15 minutes. If your blood sugar is still less than 70 mg/dL, repeat this process. Once your blood glucose levels are above 70 mg/dL, eat a snack with protein and work with your health care provider to keep your blood glucose levels above 70 mg/dL.
- 2.Take glucagon: Glucagon is a treatment for severe hypoglycemia that is prescribed by your health care provider and kept on hand just in case it is needed. If you are treating your diabetes with insulin or are at high risk for hypoglycemia, you should always have glucagon with you.
- 3.Talk to your NP: If you experience hypoglycemia, you should always follow up with your health care provider. Make sure to bring your glucose level logs and any notes about your hypoglycemic episodes (symptoms, what happened right before the episode, how it was treated).
Continuous glucose monitoring (CGM) is also an excellent tool to monitor trends in glucose levels, identify developing hypoglycemia and often avoid hypoglycemia by addressing it before it becomes an issue. CGM systems provide alerts if certain predetermined hypo- or hyperglycemic thresholds are exceeded. Enroll in Updates in Real Time Continuous Glucose Monitoring Use for Nurse Practitioners to learn more about this useful and impactful technology.
Join AANP for a free, on-demand webinar that takes a deep dive into hypoglycemia in diabetes. Two NP experts in diabetes care discuss hypoglycemia prevention, preparation, identification and treatment in detail and provide case studies that will allow you to apply what you learn. Enroll in this webinar today.
Combating Lung Cancer Through Early Detection and Treatment
By Adam Schragin, AANP Communications Writer and Editor
Lung cancer is the leading cause of cancer death in the U.S., yet studies show lives can be saved through early detection. Fortunately, nurse practitioners (NPs) are at the forefront of efforts to screen for lung cancer as early as possible.
National Cancer Prevention Month is an opportunity to raise public awareness about the causes and prevention of lung cancer and to encourage early detection of this disease. Screening works — “If lung cancer is caught before it spreads, the likelihood of surviving five years or more improves to 60%,” states the American Lung Association. Timing is crucial, and to increase early detection, an NP-led, centralized program was developed to screen “individuals at higher risk of developing lung cancer with a low-dose computed tomography (LDCT) scan,” as detailed in an article in The Journal for Nurse Practitioners. The results were conclusively positive — when early detection is combined with compliance on behalf of individuals with lung cancer, lives are saved.
The American Association of Nurse Practitioners® (AANP) spoke with AANP Pulmonary and Sleep Community Co-chair Temitope Fowora, DNP, CRNP, FNP-BC, to obtain her expert perspective on the treatment and prevention of lung disease — and lung cancer in particular. Fowora emphasizes the importance of obtaining a patient’s complete history and being proactive about referrals and testing. “Early referral is the key,” explains Fowora. “If someone has a dry cough that is not related to infection and not related to allergies, then getting a chest X-ray may be your first step to see if something is going on. In most primary care offices, they also have something called spirometry. It’s very fast and easy to do — and indicates if the patient has a risk for obstruction or restriction. Getting a patient’s history is another key part. If a person is saying, ‘I’m tired all the time, I’m not sleeping well,’ or ‘I go to sleep and I wake up every two hours,’ that is a red flag. Seeing how long the problem has been going on or recommending a home sleep study is a starter. Any provider can do that — you don’t need to be a specialist.”
When it comes to preventing lung cancer, Fowora points out that “smoking remains the number one cause of lung problems.” To combat the risks of tobacco use, Fowora recommends increasing education for young adults about the dangers of smoking. “When you’re young — it’s cool, but it catches up with you years later, and then the symptoms are shortness of breath, coughing … all before the diagnosis even comes.” As important as tobacco cessation is, Fowora also points out that exposure to pollutants in certain types of employment also poses a risk to lung health. “People who work in fields like construction or welding, they’re constantly exposed,” she says. “Consistent exposure for a long period of time definitely increases the risk of lung issues in the future. People who have a job that is considered higher-risk should be sure to use personal protective equipment — masks, gloves, shields — just to minimize those risks.”
Fowora recommends the AANP Pulmonology and Sleep Community for any NP, but especially those “working in a primary care setting and who are looking for a specialty.” Fowora tells AANP, “The group is also good for people who are new to the specialties of pulmonary medicine or sleep medicine. It is a community that can provide guidance for new graduates or new members to the specialty.”
Fowora also adds that the group “provides resources to community members, and we provide education and information to anyone who needs assistance or clarification. We are rubbing minds together. For anyone out there in a private care setting curious about pulmonary or sleep medicine, joining this group and community is a good place to start.”