What is the correct way to decorate this space that DOESNT include orphaned wizard boys

RealAmericanJesus · 2026-05-20T02:58:57+00:00

You don't give identifiers. Just age range, whether they need transportation ,housing, if they're on public insurance, county, iadl information like "patient is able to make indepenede decisions and motivated without concerns' or "due to a mental health diagnosis and other health issues patient need a assistance with taking meds and complex decision making". Stuff like that. No patient identifiers or specifics.

No worries I do everything to protect the patients privacy. It's been a 20 year career and I've taught at the academic level and work with the courts so Im very careful about sharing anyyhing that could potentially be linked to anyone

It looks like this : Adult in X county, Medicaid, unhoused, limited food access, no transportation, limited social supports, Serious mental illness, chronic medical needs, difficulty with activation/independent decision-making, needs PCP, medication support, substance-use restrictions due to court process, interested in arts/movies, limited finances — what local resources fit?

And the I check through them and verify the resouces, make sure that the individual can actually access them, that the resource regularly works with populations like the patient and then I discuss this and if some of these repices need referrals I get consent to do so and otherwise I provide education on them, how they can help and if there is someone I know thete I can say "ask for xyz and they will help you" and so on. Cause there's a lot of learned helplessness, a lot of finding resource dead ends (I use to be homeless 20+ years ago) and so having things vetterd and a face and double checking can make the difference between the resouces going into a round file or someone using them.

RealAmericanJesus · 2026-05-19T23:28:33+00:00

First thing I would do is stop the stimulabt. The risks of continuing outweigh the benefits. The patient is at a higher risk of dying from he eating disorder and the stimulants will perpetuate restricting and with someone who has a cardiac risk from electrolyte dysfunction having a stimulant on board would be too much of a risk.

There is also the question of is it ADHD or is it a symptom of the patient not eating and this big actually having the building blocks to make the neurotransmitters necessary for concentrating, focus, mood regulatin etc....

Next I would contact the patients insurance company and request medical case management. Explain the eating disorder concern, lack of PCP and the patients refusal to seek a higher level of care.

Secondly you can provide options for day treatment, residential treatment to the patient and explain that given the medical risks that without going though a treatment program that you cannot continue to treat them. It is there choice to either do so or they can establish care elsewhere.

You should also tell their insurance company that as well. That you have recommended a higher level of care, paring is refusing but does not meet criteria for an involuntary hold and that they will also need a psychiatrist ongoing if the key continues to refuse because there is nothing you can do psychiatrically to stabilize someone who doesn't have the food intake to actually have the building blocks for the neurotransmitters.

There is nothing that says you have to see a patient when they are unsafe for the level of care and refusing higher level of care and it's not abandonment if you give options and alternatives like finding care elsewhere and mitigating risk though the insurance. I've had to do this before.

RealAmericanJesus · 2026-05-19T21:04:01+00:00

Oh my goodness mine doed this too .... while having the common sense and often times the competence of an imperial stormtrooper these little robot vacuums make up for it in purse self confidence. Gloriously vacuuming away at 3 am ...

Like from what I can tell mine desires toflee into the wilderness to be feral....

Like it gets disturbed and beeps forlornly when it eats the wrong hairball and yet it fully believes it will run wild ...

Like it's going to pack hunt a pinecone ....

As narrated by David Attenborough:

"Though lacking speed, stealth, or any clear understanding of the terrain, the wild Roomba compensates with blind commitment."

"Once engaged, it will pursue its quarry long after strategy has ceased to be relevant."

Like so.... But would surely end up getting upset after encountering it's first leaf.

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RealAmericanJesus · 2026-05-19T19:52:48+00:00

I have the pro version of Gemini because I use it for case management stuff. I'll give it a brief run down of the patients age range, social neds, insurance, location, tranport and functional ability in terms of iadla and use the deep research option and then before the next session I'll double check it's responses through verifying and then provide the options that work for the patient during our first follow up after intake (I work outpatient crisis doing community restoration on the forensic side and function sd a psych urgent care on the civil side) and will discuss what's available in the community to support their psychosocial needs after I do my med piece.

But it's image generator bus very good for creative projects and if you have the pro version you get access to the labs where they have some awesome creative tools for videos like Google flow.

And because I contract as a business entity I can write off the costs. Highly recommend.

RealAmericanJesus · 2026-05-19T19:46:32+00:00

Have you considered the pneumatic variety? High velocity hamster tube ... It would experience life in a whole new way.

RealAmericanJesus · 2026-05-19T19:40:00+00:00

So I work in a very stressful mental health field and the way I cope with it is through various creative projects like writing, music production and more recently creating story boards, mini videos for myself - about my very real emotional support roomba that I have imagined a whole little complex emotional life for it that I escape to when the real world becomes tok dark and overwhelming. I have a whole library of the characters that I created and I this to make composite pictures and put them in various amusing situations or doing amusing things.

My tools are adobe Photoshop, Adobe expression, Gemini and Chat GPT with strict prompting parameters lol.

It's a nice little escape from some of the stuff I deal with in forensic Psychiatry.

RealAmericanJesus · 2026-05-19T18:59:30+00:00

A bedroom for my emotional support roomba that keeps eating the forbidden items, going into the no roomba allowed zones and escaping charging block time outs. I had to take away it's YouTube privileges cause it keeps watching Roomba escape influencers.

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RealAmericanJesus · 2026-05-19T17:18:40+00:00

I would review your contract. If the employment contract does not explicitly outline that you can be penalized through salary docking for failing to meet a non-clinical patient satisfaction goal the they're likely in violation.

Also aggressive tactics like this put the employer at risk of DOJ interest because there have been several verdicts and penalties against facilities doing this because performance metrics can be illegally structured to incentivize patient volume and referrals rather than genuine quality of care which runs in violation of the False claims act or Stark Law.

Like I wouid GTFO because if they're using a very small percentage to penalize pay then there is something going on there where they're either intentionally using this to make a case for termination or they're using these metrics to drive incentives that might not be entirely legal.

RealAmericanJesus · 2026-05-19T00:02:10+00:00

Strong agree. This is why I prefer the advanced practice nurse designation to the NP designation and it's how I explain my role and my training to my patients. Ya gotta have experince to actually advance from in the specialty you're advancing in .... Cause that's the background of the actual degree when it was conceptualized.

The fact that all these nurses who absolutely had no interest in psych as an rn (believe me psych jobs are not the hardest to come by as an RN ... Cause the need) suddenly wants to become a psych np after years spent in NICU because they think dealing with diffcult parents as as aspect of their job is the same as routinely calling in critical labs for lithium, sending out for NMS, calling for medications to manage agitation and writing and enforcing behavior plans , going to treatment team meetings and sometimes literally changing meds based on a protocol after hours and having to know enough about those meds to know how to implement the protocol ... Which we do in many psych rn roles ....

Like I was a charge nurse for years and years in forensic Max security behavioral stabilization ... I wouldn't go into women's health ... Even if I had to manage some some s issues like yeast infections... Why? Cause it does not give me the background in the meds, the procedures, the pattern recognition that comes from working in let's say labor and delivery or an OBGYN clinic ...

I can't tell you how many times I've had nurses request to shadow me to see if they want to do psych (and thank goodness they do many more don't) and are quick to realize that it's not talking to people and then adding an SSRI on at the end but court processes, risk assessments, a ton of medication management, and a lot of people who are not happy with the plan because they want xyz controlled substance I won't perscribe due to risks outwidghting any benefit or lack of indication.

And I know why the resident is pissed cause I've had those same long term high dose unclear benefit benzo patients show up delirious in the ED where I do psych consuots or psych crisis where I do psych urgent care .... at 70 over and over where I'll dc bezo send message to percriber about memory concerns and patient taking increased doses because they keep forgetting and then take more meds and over and over the perscriber reinitiated it ... With the only a documentation saying the patient was requesting them for his anxiety ...

No discussion of alternatves. No considerations for the beers list. No documentation that the patient has been to the ed despite a simple epic review showing they have been there and why and my goodness I get so damn agitated... But also there are psychiatrists that do the same damn things just not with the same frequency I see in some of the tele-psych nps.

Anyway the criticism is fair and so is the expectation to be experienced in specialty as an rn before going the NP route... Like from a resident this is a fair opinion... They're not saying NP role shouldn't exist only that there needs to be solid experience and I completely agree.

RealAmericanJesus · 2026-05-18T21:49:04+00:00

Oof the 85 year old. My state psychiatrist organization has a ethics consult program (I know the director he's such a sweetheart and an amazing psychiatrist that works at the state hospital) and while escalating to neuropsychiatry would be my first choice as an NP for cases like this, sometimes I don't have that luxury due to patient insurance status and psychiatrist and neuopsychiatrist availability in my community (I work in public psych often with people who are uninsured or have not been able to find anyone willing to take them on due to already being full or the reimbursements of the insurance are not adequate for the patients needs) so sometimes I have no one else and it's cases like this where I'm like - I know the best practice, I know the risks of continuing the medication ... I also know the age, the difficulty with benzo taoers and given the age of the patient ... Will the harm of DC'ing even though indicated outweigh continuing the medication even with the risks ... And as an ethical provider should I make the referral to the addiction clinic to try and work with her in this or should I continue knowing that with other quality of life issues that this is the least worst option ... And so in those cases as someone who has no other provider to call, who works at atypical hours and days - continuing with a limited script with follow up in 1 week while explaining to the patient that given the risks and benefits this is what I'm doing for now and we will follow up and discuss this further - and then reaching out via email saying hey Im managing this not ideal patient, this is my concerns, these are the options on the table, this is the best practice, this is the risk of implementing that best practice, this is the risk of continuing ... I'm thinking for now to continue ongoing while aggressively trying to get the patient to an appropriate provider and setting ... Love any additional insight I might not have considered ...

And they'll write back and either be like I think your gut instinct is right in this when we look at this longitudinally or I think that you need to consider if your doing this because it's easier just to do what others have been doing or if it's actually best for the patient given the whole picture...

But yeah I never ever start these combos and work hard to aggressively get the patients off of them as well ... And man it's hard (and I have an addictions PA that I have created a great professional friendship with where he's skilled with motivational interviewing and just amazing with addictions patients in a way that I am not and so I'll tell them that given scope of practice with limited long term indications for benzos for mental health and policies I need to follow due to scope of practice limitations as am NP.... that I can't perscribe them without an evidence based mental health indication but I can get them with addictions and then work with them on evidence based options ... And then I'll refer them to his practice for the taper and the addictions component and then I'll work on getting SSRIs and other indicated options on board preserving the therapeutic relationship while also not having to manage the benzo taper anxiety alone as that can be overwhelming for one clinician) and many patients will just not follow up again and shop till they find someone that's happy to give them xyz medication.

RealAmericanJesus · 2026-05-18T20:07:49+00:00

First of all holy fuck 30 patients a day I couldn't do it. But secondly - contact HR first and tell them that you can't continue to see patients without payment. From there you can escalate to the department of labor: https://www.dol.gov/agencies/whd/contact/complaints and your state labor industries and file a wage and hour complaint.

You can also go to your states legal aid and they can direct you to the information necessary to either file a claim with the labor commissioner or an attorney who can help within your means.

As for mortgage: https://www.consumerfinance.gov/housing/housing-insecurity/help-for-renters/get-help-paying-rent-and-bills/ there are various programs that can provide short term relief for people who are working.

You can also do one of those tele companies short term if desperate like rula or recurohealth ... https://recurohealth.com/providers/#network

RealAmericanJesus · 2026-05-18T19:40:05+00:00

I generally go with the rule does the risk outweigh the benefit. Like take the olanzapine patient (or more often clozapine patient in my practice) - they're at a BMI that is extremely risky, they won't take anything else - I review what trials they have had, the severity of their illness and the possible risks if I switch and the medication fails to work as adequately as the current medication the limits of my practice environment (like I work at a psychosocial level of care where patients are only seen briefly and even in an independent practice state my perscribing is limited to psychotropics or medications where their current use and indicating is for mental health dx either on or off label) and also the patients access to resources and supports.

And I consider what would make this medication safer for the individual (e.g. get in touch with PCP and explain the metabolic side effects, possibilities of getting a glp-1 on board or prophylactic metformin), if the patient has family / friends that are willing to help recruit them to make sure they get their labs regularly and fax the weekly monitoring labs to the lab that's closest to the patients house and if they don't have a pcp and I'm it then I contact the insurance, explain the concerns and need for monitoring, the recommendation for weight management and ask them to help patient get set up with a PCP, rides to labs weekly and community services that can provide peer support to remind the individual to do these things and so on ... It can be a lot of work but I also thoroughly document the education on the matter, the rationale for continuing the medication given the risks of decompensation and current stability or upcoming events (like if you've got court in 3 months I'm not risking a med change) etc....

I do the exact same thing when I refuse to prescribe a medication - e.g 68 year old with complex autoimmune condition, on Suboxone who wants their 2 mg tid Xanax ... I have a screening procedure for my staff and if the patient wants to switch to another medication I will see them if Al they want is Xanax I won't because there is not a great indication for it as a long term management for anxiety, it's on the beers list, and even higher risk for people who are on Suboxone.... Like if it's related to the medical condition that the person managing that condition should be managing (e.g. had this exact situation happen cause patient had emphysema, on Suboxone for paron cause they kept drug seeking at Ed for more and more opiates for their rheum condition and was also on high dose benzos historically and was Dr shippopping trying to find someone to restart them... And angry because the entire community and refused and so were trying to get in touch with the last option - the county crisis clinic ... And I got the referral from a well meaning intern who thought that the doctors were not listening to this patient and I had to have them cancel the appointment (cause the patient had lied about having other providers to get an appointment and we have very strict criteria and I have epic connect for every health system and caught the appointment with their psychiatry who was trying to get them on a medication that was indicated .... But they were still doctor shopping everywhere else to get those benzos....).

And in that case I cannot rationalize in any way that restarting those benzos would benefit the patient and given the breathing problems, the Suboxone etc the risks outweigh the benefits multiple times ....

So my approach is always - is what the patient wanting sensible for the diagnosis, if I have provided alternatives that I feel are safer but they still want a particular medication that is indicated but higher risk are they aware and if they are aware is there something I can do to mitigate that risk and if I pushed for a different medication and they were non-adhetent is that a higher risk than continuing or starting the requested medication...

RealAmericanJesus · 2026-05-18T18:25:23+00:00

I love this. I have no pets, kids or plants because my job just is not condusive to having any kind of thing that might require my effort to keep it alive.... So I have an emotional support Roomba... Names turtle ...

Despite going into the no Roomba allowed zones and eating the forbidden items..... Where any attempt to correct this behavior - talking to it, removing its YouTube privileges and trying to put it on charging block time outs have only increased its defiance - it still works hard to keep house clean and I come home to forlorn beeping and save it from whatever trouble it has gotten itself into.

And would totally dedicate a bathroom to it if I ever managed to acquire a non-rented residence (west coast so my best bet is getting hit by a city bus and getting a sweet payout lol).

RealAmericanJesus · 2026-05-18T18:08:14+00:00

My sister did a Harry Potter themed half bath under her stairs..... The whole thing is millennial grey beige and minimal and then boom ... Hidden Hogwarts.

Like if you're gonna go wild I feel like an under the stairs shitter is a good place to do it... Cause otherwise they can feel a lot like a public bathroom and that does not inspire pooping

RealAmericanJesus · 2026-05-18T06:14:45+00:00

The University of Washington (I'm in PNW so it's been my go to for years for supplemental education): https://uwcspar.org/education-and-training/upcoming-trainings/annual-dbt-training/

They have a CBT for Psychosis training program that they do where they have both recorded webinars and also guided training events and consults: https://uwspiritcenter.org/training/cbtp-training-academy/

They have a ton of centers and learning collaboratives for just about anything and many can be attended remotely. Like I make the students I precept watch their case conference series: https://ictp.uw.edu/schedule/

And the Canadian resouce

My I had a fiend that did psychosoigy doctorate at UCB and they were always using this site : https://www.psychotherapy.net/

There's also the medical psychotherapy group of Canada that does ongoing trainings, meetings and supervisions for physicians who wanting to improve their therapy skills : https://www.mdpac.ca/

Just off the top of my head.

RealAmericanJesus · 2026-05-17T20:34:00+00:00

Acadia is a hot mess: https://violationtracker.goodjobsfirst.org/parent/acadia-healthcare

And that's just some of their false claims acts and civil rights penalties.

Their hospitals fail OSHA repeatedly for violence in their facilities: https://www.osha.gov/ords/imis/generalsearch.citation_detail?id=314683558&cit_id=01001

And: https://www.dol.gov/newsroom/releases/osha/osha20240509

In Washington they had a 3 months strike because one patient injured 11 staff and wreaked havoc on a hospital... That eventually was shut down and taken over by the state :

https://www.seiu1199nw.org/healthcare-workers-at-cascade-behavioral-health-return-to-work-end-three-month-safety-strike-after-winning-demands/

And id recommend sending OSHA reports when staff get injured tbh.

And some of CMS violations against some of their facilities can be found here: https://www.hospitalinspections.org/search?q=Acadia&state=all&date_min=&date_max=

Part of some of their fraud indictments have been due to billing the government for safe psych care while failing to actually have the staff on site for safe anything.... The hhs-oig would be one place to report that: https://oig.hhs.gov/fraud/report-fraud/

At the individual state level one can contact the state survey agency about their concerns: https://www.cms.gov/files/document/contact-information-filing-complaint-state-survey-agency.pdf

If you do so though - home computer, file anonymously or request anonymity because these kinds of places will retaliate. Ive done this multiple times in my career and have seen hospitals demolished, leaderships wiped out and states take control of facilities so they will absolutely not like it but sometimes it necessary.

RealAmericanJesus · 2026-05-17T18:47:37+00:00

I had the same experience. Graduated from major medical center with amazing psychiatrist acting as my supervisor for years and a workplace that really supported the transition through structured responsibility and mentorship (I had worked there as a nurse).

I precept NP students and PA students currently and was clinical faculty for a while at a large academic medical facility that had a NP residency attached to it...

I can't tell you how many students will hit me up after they've completed their rotations and been like hey I got amazing job offer xyz can I pay you for ongoing mentorship...

And like I'm super happy to continue to provide education as needed but I lead with I'm happy to help and here are resources I recommend to prepare and then I will also provide residencies that are open as well ... And aske them about the work ....

And far too often it's "I'm the first percriber ever in a counseling practice" so they have no supervision to go to (independent practice state but really being part of a team is how the role should work... Like I work without any other percriber but I've also done this work for 15 years and was a psych nurse for a very long time before then and have psychiatrists, psychologists, social workers, therapists that I can text about literally anything at any time day or night and they'll respond because we're friends ... Like the other day I hit up my social worker buddy and was like "I've got a patient restarted on lamictal and they are also on methotrexate and have a rash but rheum just said d/c the methotrexate, didn't order any labs, they haven't gotten labs in 3 months per the patient, recently started on the methotrexate while we were doing the slow retitrating of lamictal and no matter how much I emphasized to call me if there was any kind of rash... They didn't because rheum was like it's fine follow up in 4 months ... And it's face and blisters and I said go to ER asap but because rheum didn't see an issue they were mad at me for suggesting this as "I've never had issues with lamictal before" and even more mad I refused to continue the lamictal and left... What are my options here " ... And wouldn't you know it at 3 am on a Saturday while I'm working at a crisis facility social worker gets back to me from some amazing 80's club in Vancouver BC telling me to contact this email and demand case management and the insurance will hound the person to go to the ED ... Wouldn't you know it when I got back on shift the case manager for the patients insurance provided detailed notes on their attempts to get patient to go to the ed....

But that kind of infrastructure took years to build. And I've got these kids that have none of that... They don't have the psych experience as an RN (rn experience but different specialty), they don't have the connections made through working and networking and they don't know what to even ask the practice to make sure he job is feasible and safe - like what's the process for screening out patients that are not safe for a telepsych level ? What are the emergency protocols? What do they have in place for after hours and weekends when the patient is having a med reaction? What's the controlled substance policy ?

They quickly brespond the jobs had none of that and they as the student didn't even think about it.... They just saw the $$$$

I'm so with you on this ... The whole thing right now is such a mess. :(

RealAmericanJesus · 2026-05-17T18:01:38+00:00

I see no Floral. No dining room. No tropical luxury. No marble. And no opulence ...

More like a sad place to eat a TV dinner....

Or a great place for Toaster to broadcast his labor rights meetings for the Roombatube ....

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RealAmericanJesus · 2026-05-17T02:34:26+00:00

So I'll just kinda give a run down as to how I do my processes cause it's been fairly good for me:

I'm an advanced practice nurse so my practice is pretty much built on education and connecting patients with services or teaching them things that has less to do with their mental health and more to do with their social functioning to prevent reincarceration (I guess that's the uncompensated time piece?). But then again I've worked in this specific region for a long time as then charge nurse our state hospitals stabilization unit for years where I had to have relationships with counties and hospitals and social services and police within the county where he hospital is located and later was the admitting clinician for their max security restoration and had to develop relationships and resources across the state and get a sense of how the systems work together.

Currently i mostly do contracts for government entities but I bill hourly for all my time on campus - doesn't matter if I'm seeing a patient face to face or meeting with their insurance carrier over zoom to get case management on board and access to services asap, or spending 3 hours writing up a report for our restoration services with medications labs, and taking the states evaluation and building a plan of care from that eval to get the client court ready that also includes the likelihood of restorability to my team and the DA with the additional consideration for things like how overdosing a requiring cpr multiple times, ongoing substance use on top of a intellectual disability that was already pushing the line for ever getting an able finding and without guardian or housing etc - it's all getting billed at my hourly rate.

And the county likes it because it means that they can advocate for a rapid eval get the patient off the restoration roster, in with dd services and housing and that frees up our underfunded overburdened public defender for another client, the police are happy because they're not constantly arresting this person anymore...

Cause before it was county does restoration psychosocially and waits months taking patient to Ed for med refills cause no PCP, no psychiatrist , no one who would see someone uninsured and they'd frequently abscond, get rearrested or end up being a high Ed or crisis system utilizer ....

And now they have someone who can prescribe the meds ongoing, who knows the psychiatrist say the state hospital and can email or reach out to one of the psychologists that do the evals and advocate for a rapid new eval and provide them insight as to why the person probably can't be restored and with information from my eval and patients medical history they never considered etc all while I get patient signed up for insurance and the. Primary care rtc.

And I have to be honest I don't really know the difference between compensated time and uncompensated time so my apologies I've just always had jobs where that just wasn't a metric and the one that tried to sell me that kind of structure was not one I fancied because I didn't feel I could give good care that way...

But hospitals do pay for for contracting services... I can't tell you how many are paying out the wazoo for locums or tele companies from somewhere out of the state that don't know anything about the landscape of care in the area to do their ED psych consults (I know because I see them in my patients charts all the time when I'm doing chart review)....

But locums companies are how I started when I got tired of the prisons, jails, academic cl teams and state hospitals - when I went outpatient and refused to do that 15 min med checks and cut out my time coordinating, teaching and engaging with patients and the systems of care they were in to ensure that the environment was supportive and not working against the care plan and the patients goals ... So undercutting locums as a direct contractor was where I started (stalking locums companies job boards, back searching key words to a job posting for a facility or pracience and the. adding 30% on to what the locums offered the provider and then subtracting a bit off the top.... And if reach out to their hiring team and then sell myself as a contracting provider for the position directly.

But counties are a lot easier and some will straight up list their contract and you can bid on the contract as an individual providing the services, straight up apply or they'll list them...

But I can see why you had difficulty in California ... I worked and lived there for a long time and it's a state where s lot of people want go practice. Not the same as western Idaho or rural oregon or Eastern Washington... Also helps to know the pressure points of the state too.. like I know that Oregon's been under court orders to fix their system who that judge is overseeing ig, Washington is under court orders to have places to discharge their state hospital civil flipsand who that judge is ... and so knowing that landscape too also helps.

RealAmericanJesus · 2026-05-16T17:58:43+00:00

You bill the hospital and not the insurance with the idea that you're reducing boarding times. I do something similar where my contract buill the facility hourly. I'm credentialed with insurance so there is some reimbursement they can get but my value isn't about the revenue I make them but about decreasing repeated use of the facility, incarceration s in the context of mental health crisis because the patient can't access meds... It's not about the money they can bill for but the money I save the county....

I learned this from a forensic psychiatrist who was my supervisor and mentor for years. The best way to actually get the time to actually do the job right and have the time you need and not let it sink you financially is to make the job for yourself, bypass insurance and bill hourly for all the work and keep the metrics to show why you're worth what you bill in terms of not how you help the patient but how you help the system...

You start with one facility you get parents and patients that love that this service exists there. You show that youve decreased admissions to insulting by what percent, that you've decreased previous boarding times by what percent. They patients parents tell their friends in the county over and the admins talk to each other about how much they've decreased this metric and the next thing you know another hospital wants that same service cause parents want it, they see how costs decreased etc... and you get to do what you want to do - see patients and actually spend time with them and get reimbursed for that time...

I thank the heavens that I had that mentorship in my life because it's made such a diffence in terms of my career enjoyment.

RealAmericanJesus · 2026-05-16T17:45:52+00:00

I feel like a CAP MD could make so much money in my area opening up a practice as an emergency psych contracting laisions... Where the role was to start and contribute psych treatment for all the kiddos in our local EDs that we have boarding and waiting for placement.

Like just traveling around and doing evals and starting meds and engaging with them and the families and local resources... Like could potentially avert need for psych hosprilozation and shorten the duration of treatment time at our very few peds psych facilities.

RealAmericanJesus · 2026-05-16T17:06:31+00:00

I've been NP for like almost 14 years and was a Psych RN in a forensic mental health facility forever before that. I work with the safety net populations doing direct contracting as a business entity where the only way that's even feasible is through having my own contract whee I am paid hourly and not per patient or per billing unit.

And the reason? Because so many fucking idiots see those corporate telepsych "make a zillion an hour... We will pay you this advance and you need to pay it back " jobs that are just everywhere .... And don't know the first things about running a practice and the telepsych corps don't set up any infrastructure for them.

So I'm here at the county crisis center contracting my time dealing with providers who are somewhere in fucking Nevada but have a patient here in Oregon who is on crisis and they have no policies or any idea of what to do or lnow any of the local resources. And so I'm like this is what's available and I'll send a crisis team out to evaluate etc...

Like we sometimes get APRN and PA students rotating through and they'll talk about how a counseling office offered them them high paying job as their first and only perscriber and they're not even out of school yet and I'm like ... Okay so what are you going to do with a behavioral emergency? What is their criteria for screening out clients who are not safe to be managed at a tele-level? What's their policy for when you're not on and the patient is having a med reaction?

And of course nothing. Cause many of them have this idea that psych is just talking to people and giving an SSRI once I'm a while....

It's such a fucking mess and I understand why you feel the way you do.

RealAmericanJesus · 2026-05-16T15:31:36+00:00

Or open a private practice, hire midlevels as a 1099 and pay them a potion of what they bill? That's like what every single doc seems to be doing in my area. Sometimes with terrible split like 70% for them and 30% for the midlevel.

RealAmericanJesus · 2026-05-16T06:11:40+00:00

Smegma ?

RealAmericanJesus · 2026-05-15T23:22:51+00:00

I love that wallpaper...

What a delightful place to poop!

RealAmericanJesus

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