Managing Chronic Care Visits for New Nurse Practitioners
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Show notes:
Chronic care conditions are a big part of working in primary care, but they’re also complex, time-consuming, and stressful to treat, especially for new nurse practitioners.
So this week, we’re going to do a walkthrough of how you can conduct these visits, but in a way that that feels timely, organized, and safe!
How to Manage Chronic Care Visits in Primary Care
In this video, I touch on the 4 most important steps to take in each chronic care visit:
✅ Reconciling medications
✅ Assessing the status of their condition
✅ Identifying the red flags for the most common chronic care conditions in primary care
✅ Determining the extent of specialist care
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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In this week's episode, I want to talk to you about chronic care visits.
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I know these types of visits can be really overwhelming, so I want to talk about the
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general way that I approach my chronic care visits and how to do it in a timely and
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organized way so that it's not hours and hours long, and it's also done in the
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safest way possible.
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I also have some quick tips and little pearls of practice to share in there as
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I usually do.
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Before I jump in, I just want to share that I'm really excited.
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I'm working on a brand new course to help with chronic care management in primary
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care, specifically with adults, so the management of diabetes and medication,
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hypertension and hypertension medications, as well as a component of chronic kidney
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disease, so the assessment of CKD, diagnosis, monitoring, things like that,
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when to refer, all that good stuff.
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So that's a brand new course coming this fall.
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So if you want to join us for that, it's at realworldmp.com slash courses, and I
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have the feeling the first version is going to be live with viewers truly.
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So if you would like to attend that or if you're interested for more details
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and you're not quite sure yet, still get on that wait list because you'll
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be the first one to find out.
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However, let's get back into this episode.
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So when it comes to chronic care visits, these are super common in primary
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care.
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It's usually a chronic care visit followed by an acute care visit followed by
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acute care, meaning like not hospital care, but like something urgent, like an
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urgent care type of visit, sick complaint, et cetera.
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But the vast majority of primary care is chronic care management, and the
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top three conditions are diabetes, hypertension and CKD, and they're all
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tied together.
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So I want to walk you through how I conduct these visits, and hopefully this
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will help keep you from feeling overwhelmed and feeling more confident
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with how to conduct these in a safe way.
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So step number one that I always do is medication reconciliation, or I always
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endeavor to do.
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I'm not perfect, right?
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The real world here.
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I try to start with medication reconciliation, especially if it's
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someone that I've never met before.
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And this is incredibly common in primary care with new grads because
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everyone's new to them, right?
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So the way there's a couple of ways to do that, and I have a couple
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hacks there.
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So number one, you can ask the patient, of course.
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The other one is hopefully you can involve your staff that work with you
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in a systematic way where your medical assistant or whoever it is that's
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rooming your patient will also ask about medications and start that
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reconciliation process for you.
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Again, it's your license, so you have to verify if it's somebody who
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doesn't have a license that you do, right?
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If it's a nurse, it's different.
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But they can start that process.
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Hopefully the other thing is that the patients have a medication list
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with them, maybe in their wallet or something like that.
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But if they don't, hold that thought.
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And the other one, the really beautiful pearl of practice that I
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got recently working with, excuse me, doing an interview with a
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pharmacist is collaborating with your local pharmacist.
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So this is easier.
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If you haven't watched that already, definitely go back and watch that.
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It's wonderful.
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But the main thing about that in terms of collaborating with pharmacists,
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this is easier done in a community health center setting that has a
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community pharmacy associated with it versus the larger commercial pharmacies.
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However, one of the things that she said that she loves about being
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a pharmacist is that she's a hub for the patient.
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So many medication issues come from specialists, various specialists, as
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well as the primary care, prescribing the same medications, making
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changes and not fully communicating with each other.
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Whereas the pharmacist is the front line for that and that collaboration
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and that communication and all that stuff.
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So that's the first thing.
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Medication reconciliation is just a safety thing.
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And it also helps you very quickly get the status of the chronic
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conditions in front of you, right?
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Especially if you've never met them before.
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So that brings me to my next step.
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So step one is medication reconciliation.
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Hopefully with the aid of your medical assistant or nurse or
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whoever rooms the patient for you.
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The next one is just regardless of the chronic condition in front of you,
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whether it's a rheumatologic condition, diabetes, hypertension,
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CKD, et cetera, et cetera, right?
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Whatever the chronic condition is, asthma, COPD.
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What are the signs that it is stable, worsening or improving?
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Like, what is the status here?
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Again, that kind of quickly ties you from the medications,
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depending on how many they're on in the doses.
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What's the status?
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Like, where are we?
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Let's orient ourselves.
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Are we stable?
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Is this patient getting worse?
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Are they improving?
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And then generally speaking, this takes some learning and some studying, right?
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But just knowing, like, how would you know what are the questions you would
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ask to determine if they're stable, worse or better, right?
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And again, this builds with time and with knowledge and even just muscle
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memory, because I know it feels like we don't have enough time,
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especially as a new grad, when your brain hurts at the end of the day
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and you feel like you have absolutely no time to just, like, do anything.
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This can also come with muscle memory, when you start doing the same things
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over and over again.
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And I have to say, if you've been following me for a while,
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you know that I do things in a systematic way as much as I can,
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because it reduces that mental load when I do the same things
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in the exact same order every single time.
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And that works for me.
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That might not work for you, but that's a muscle memory thing, right?
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So again, how would you know this chronic condition in front of you
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is stable, worsening or improving?
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And then can you ask them, right, how they're feeling symptom wise?
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Which brings me to my third point, which is about red flags.
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So what is the absolute worst case scenario for the chronic
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condition sitting in front of you?
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And I should have started with this context of usually
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the situation is a new nurse practitioner.
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So I work with a lot of new grads.
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And this comes up a lot where they're seeing the patient
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for the very first time.
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They're, you know, for example, like an 83 year old patient
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that has multiple chronic conditions and a very long medication list.
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That type of scenario can feel very overwhelming,
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even for experienced providers.
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And so this method that I'm describing is a way to really like anchor yourself
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and make sure you're not missing anything and that you're giving
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the safest care, right, especially in the face of like so much to assess.
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Right. These are these are like the get to the heart of it.
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Bare minimum safe care elements that you can incorporate into your practice.
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Right. So, again, just recapping.
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Number one is medication reconciliation.
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Even if you don't know what meds this person should be on for their
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polymyalgia, rheumatica or whatever their chronic condition is.
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What meds are they currently on?
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Let's just start there.
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Collaborating with our our pharmacist, if we can.
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They're wonderful resources for us.
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What are the signs that it would be stable, worsening or improving?
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And can you learn that if you don't know?
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And the third thing is red flags.
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So that's kind of tied into there to like, what is the worst case scenario
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for this chronic condition sitting in front of you?
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And then hopefully you have the knowledge of at least hypertension, diabetes.
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And then as you expand your knowledge further, you can get into those
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chronic rheumatologic conditions or other chronic conditions
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you are less intimately familiar with.
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Right. But like even like just as a practice before you even see those
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patients, especially if you're a nurse practitioner student.
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What is the worst case scenario with hypertension, for example,
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hypertensive emergency?
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Right. What are the signs and symptoms that you would know
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that it was getting that you were in that state?
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Right. Do they have chest pain, vision changes, shortness of breath,
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the worst headache of their life, right?
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Blood pressure of 200 over 100.
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Right. So like, are they there or are they not?
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Right. And like, how would you how close are we getting there?
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Right. And I talked a little bit about this in the other
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hypertension video that I made.
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I can link to down below this.
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The next piece is, do they see a specialist?
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That's just one one quick question, right?
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This is like kind of like the triage based easy, like check, check, check,
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check, check for all the chronic conditions.
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Do they see a specialist?
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And when was the last time that they saw them?
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Right. And so just even asking that question,
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putting that updated info in there, you've covered your bases.
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Right. They saw them last week.
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No new orders. Everything is the same.
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Medications are the same. Perfect.
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Boom. You've assessed that chronic condition, at least the bare minimum safety.
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Right.
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I have a quick tip to throw in here is that I love the use of quick texts,
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especially when I was a new grad, because it would help cue me
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in the history of present illness section of like what I should do,
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what I should ask for each of those dot hdn dot dm.
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You know, I just made all of those.
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And so it told me what questions that I needed to ask.
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So I didn't have to rely on my memory to make sure I didn't miss,
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you know, urine microalbumin, monofilament tests, like, et cetera, et cetera.
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And spoiler alert or fun fact, either one inside of the chronic care course,
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there's going to be quick texts available for you,
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the ones that I use that you can download or you can make your own.
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And then the other kind of like quick tip there is that you can copy
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and paste your last HPI if you've seen them before.
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Right. Because you wrote it.
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You have to just you have to update it, of course. Right.
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But that's like another kind of quick way to recap.
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And I think once you'll find, especially if you're a newer clinician,
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it can feel super overwhelming to have that patient in front of you
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with multiple comorbid conditions, multiple medications.
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But you'll get the hang of this where it's like, oh, actually,
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you're here for your kind of like check in visit.
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Now I know all of these things.
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I know the status of like your regular status of all these chronic conditions.
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And it's all the same. Right.
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It's not always that beautiful, right.
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It's not always that easy.
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But like you kind of like this, this approach is to kind of get
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like a step by step of like, what am I?
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What am I? How do I orient myself?
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How do I quickly get to the heart of the safest option for this patient
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and take it from there?
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So just as a recap, so number one is medication reconciliation.
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Number two, what are the signs or symptoms
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that it would be stable, worsening or improving tied into that?
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Or what are those red flags?
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Can you assess for red flags? Right.
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Just straight up assessing for red flags.
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If you ask nothing else, what are the worst case scenario
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questions to ask about this chronic condition in front of you today?
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Next one is, do they see a specialist?
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And when was the last time they saw them? Right.
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And that gives you further confidence about, OK,
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this is probably a stable condition then.
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And then again, using those quick, quick texts
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and copy and paste tips of your own previous note.
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And then the last thing I want to wrap up with is that when to come back,
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when do we have patients follow up with those chronic care visits?
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And this really depends on the situation,
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which is like a not that helpful answer, but really generally speaking
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for stable chronic conditions, it's about every three to six months.
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Right. It's condition dependent, but it's about every three to six months.
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However, if there's something that needs to come back sooner,
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somebody needs to come back sooner, that's up to your discretion.
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If it's something that's worsened or you've made some changes,
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maybe you bring them back in a month. Right.
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If it's really severely declining or worsening in status
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of that chronic condition, it's an exacerbation of some kind.
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Again, individualized basis.
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But like that could be a couple of days to a week or two weeks. Right.
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So that's it.
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So that's my general approach to my chronic care visits.
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And again, if you want to join us or find out more information
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about the chronic conditions course that is brand new,
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this brand new this fall slash winter, it's at realworldnp.com slash courses.
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So thank you so much for watching.
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Hang in there and I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends.
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So together we can help as many nurse practitioners as possible,
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give the best care to their patients.
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If you haven't gotten your copy of the ultimate resource guide
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for the new NP, head over to realworldnp.com slash guide.
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You'll get these episodes sent straight to your inbox every week
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with notes from me, patient stories and extra bonuses.
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I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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